BAKER ISLAND - BUILDING INSPECTION F
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Material of BypdkgT ��' H dweUlny.how maml ,
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Amhitscre Name
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Address and Photo iU
Mechardds Name
Addraea and Phone HIC Reglawatbn 0
Construction Supervisors Licanse 0
Estimated Cod �,,,�",• a�oo Pemdt Fee Cala+lN090
Pent Fee S Esti nated Coat X$71$1000 Residential
_- Es*na Nd Cost X Ili IIS1000 Canwnwctsi"
— An Additional$5.00 Is added ae an
Adininigir 0ve dwrpe.
Make an
that an fields are property and wow`"fin to avoid delays In proaeeln0.
The urdersO-..d doM Eby apply for a euMN Psmdt to build to the above abated
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PUBLIC PROPERTY
DEPARTUMNT
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1.0 STE INFORMATION
Location Names g
PMPWV Addnsr.
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0 NERSHIP INFORMATION.1 Owner of Land
ew.ddress:
c.o s QKI: s1�
Telephone: 60 VI-735Y
3.000MPLETE THIS 3ECTION FOR WORK IN E111111ING BUILDINGS ONLY
Addition Existing
Renovation ✓ Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor(30 Renovated
Construction or renovation
Of existing building New
AQdcee�Jsperiptian of Proposed Work: I
- - --Mail Permit to: 4-)3 Xir4t4AVV
CITY OF SU1 EM
PUBLIC PROPERTY
DEPARTMENT
IG L
MAYa
12O WNUdNGTON&MM•SALEK MAMACHL'SEM 01970
TEL 97&74S-9595 0 FAX.976740.9&4
HOMEOWNER LICENSE EXEMPTION
Please Print
Job Location r`o � .SZ 4 k t 21
Home Owner Address L 4 Ol qQ
Home Owner Telephone / - 2 1- g - a T /
Present Mailing Address C 3 lrl An ! 41,., ,l.[n r 1 S
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFMION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner, Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned"homeowner".assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection es requirements and that he/she
will comply with said procedures and r Creme
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
120 W.w11N6:0NSTREET ♦SALF\t,S1M5ACHL-.1L11]:191C
TeL:978-745-9595 •F.+x:978.7i49846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
1n accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of vtGL c 40, S 54;
Building Permit # _. __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 1.50A.
The debris will be transported by:
(lame of hauler)
The debris will be disposed of in
- _ (name of facility)
,a1�lces,of facildYl
Si_ .1IUN of i)crn:ll dI/1LICanI .____