BAKERS ISLAND - BUILDING INSPECTION (15) PUBLIC PROPERTY
DEPARTMEINT
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"MAL14 uwtLAaast„s o1970
1 I TEL 979-745-MS 9 F.x:97L740.9646
\ APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
property Address: Lof 9 / Britcv5 Z51C- a Sri-UV^ I #AA
Property is Wcated in a:Conservation Area Yin Histafic Disaxt YTri .
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: 00k.5 gr6%-k, [o C co , Tvvj
Address: I el Nu b Le_ 14,711 A I .
f3evevly MA 019 I S
Telephone: 9 7 8 7- 3 Z q S- / 7
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIM2 BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Cowsfwc +- a IZ �t )( 23f+ DeCk Gt-�Cutet
Mail Permit to: Be r6-6,r 19 Noloi.e., Hi'II Rd , bevev)y, MA Olgi5
What is the current use of the Building? 5e&5okoj
Material of Building? 1JV If dwelling. how many units? j
Win the Building Conform to Law? `�t� Asbestos? N 0
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration #
Estimated Cost of Projed S 2t— Permit Fee Calculation
Permit Fee i Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Pk^lnlstratjYe Ch3^e*9.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
Date
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
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4AYoa 130 WAsab=C0 ftU=•SMmt MM 01970
TEL-978-7454S"• FAx 979-740.9a46
HOMEOWNER LICENSE EXEM"ION
Pies" Print
Data Z — ZY- oB -
Job Location 1 of q 6,,-12 `s 51 u• ; $o (,mow A4 A -
Horne Owner Address 19 NOWL- H:11 Rd . ev-f0X
Home owner Telephone 9 y d- 2 3 Z 1117
Present Mailing Address So-
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.
DEFINITION 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 procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE 1�
APPROVAL OF BUILDING INSPECTOR
See other side for state code
` CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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�:+q►f�►9M�f.�e t7sf��esse
Construcdos Debris Disposaf Affidavit
(required ibr an d naWba and emovarl"work)
to aaordancs with tM sixdt ad{tks of tles Sate dluildlng Coda,7S0 CI►1>t section 111.!
Debew and dw pmvisWm of MML c 40.S 54
8aildtn4 frnetit f„_,,, _ _ is isawl with tdw condi"dwA the debris ra dit Ras
this wart a wl be disposed of in s p mpwty licumml wssts disposal &duty as dented dry.%!(3L e
111.S 15"
The debris will be transported by:
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rho debrs will be disposed of in :
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