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BAKERS ISLAND - BUILDING INSPECTION (31) CITY OF SALEM PUBLIC PROPERTY ` DEPARTMENT KIlltl�w ti�N� / I a HwYoa �[ 120 wwwna[ [ M MEET•SALEK N.\SSAOUSUM 01970 Q TM-,978.73S-9S9S 9 FAX 978-740.9W HOMEOWNER LICENSE EXEIM"ION Please Print Date 7 2 O Job Location Home Owner Address Home Owner Telephone S' K 3 Q `!°2, Present Mailing Address -z� e R < e vW7' A P25 !Y/=a,5R4.L/ The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or leas 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 APPROVAL OF BUILDING INSPECTOR See other side for state code JI PUBLIC PROPERTY DEPARTNIEINT Mwros 130 Wwarw'II*a`�•&M&W%LUMCHLSkTR 01970 TEL M74i9s93•Foe 97L740,"o APPLICATION FOR THE REPAIR. RENOVATI N CONS UCTION DEMOLITION OR CAANGIE OF US>P OR OC MANCY FOR ANY EXI T—IN ` STRUCTL OR BUILDINr 1.0 SITE INFORMATION M Location Name: h 5 71- 51 ( /U� Building; Property Addreaw Property Is located in a:Conservation Aron Y/N Historic Dlshlct Y/N [Address: OWNER3HIP INFORMATION Owner of Land e: W1 7WE' - E&",f/U W1:57- F2057' S c 2 C S e 1cJ -r //phone: D 5 3 © / 3.0 COMPLETE THIS SECTION FOR WORK IN EXIS7AG BUILDINGS ONLY Addition Existing t/ Renovation Number of Stories Renovated Change in Use ( New Oemolition Existing Approximate year of f Area per floor (sf) Renovated construction or renovation l 1}v Of existing building -f New Bdef Description of Proposed Work: -- - Mail Permit to: C2�s c ;�y AU`� fsj �ekL y 3� What is the Current use of the Building? Material of Building? �� O � _ H dwelgng,hove many units?.�---- . Conform to Law? S - Asbestos? Wlq the Building � /�- Architeas Name ( 1 Address and Phone nr Mechanic's Name Adder and Phone N r{ HIC Registration a---- Construction Supervaors Lic�n�s�ei� Estimated Cost of Project ice= Pe^^M Fee Caleulagon Estimated Cost X$71$1� Residential Permit Fee i `� Estimated Cost X S"'S1000 Commercial—---- _-_ An Additional$5.00 is added as an Administrable dwge. Make sure that ail fields are properly and legibly written to avoid delays In processing. The undersigned does hereby apply for a Wilding Permit to build to the above stated g specifications. SI ned under penalty of Perjury X�tp 0 ' " ` � Date 2Ljje7 �J I ! v 0 N � a I .. y