BAKERS ISLAND - BUILDING INSPECTION (6) What is the current use of the Building?
Material of Building? If dwelling,how many units?
Will the Building Conform to Law? Asbestos?
Archited's Name
Address and Phone
Mechanic's Name
Address and Phone
Constriction Supervisors License# HIC Registration#
Estimated Cost f PrJect$ a Permit Fee C ftlatlon
Permit Fee / Estimated Cost X$71$1000 Residential
-- _ — Estimated Cost X$11/$1000 CommwcW
An Additional$5.00 is added as an
Administrative charge.
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 -
Date 6
of
06
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KI\WERIEIf DiLSI:OLL
MAYOR I20 wASHINGTON S REEr•SAI FKMASSAOiuserrs 01970
7Fi 978-745-959S• FAY:978.740-9&6
HOMEOWNER LICENSE EXEMPTION
Please Print
Date - 1(b
Job Location rB)T k(z' 2-', 5 +�
Home Owner Address a5' Gk'tSLtiUY G° fE�/�22y
Home Owner Telephone 1-7
Present Mailing Address )- :!� 11(115 l3 a Vr 2 l Y WYl Q/�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,
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 res
ponsible for all such work performed under the Building
Permit.
The undersigned"homeownee'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 �P1 —
APPROVAL OF BUILDING INSPECTOR
See other side for state code
EI"f'Y-OFgXI.E� ---
PUBLIC PROPERTY
DEPARTI4IE�tT
KINMEALEY DRL%lN I
MAYOR 120 WASMNarM Sr9EET• 'SLLka4-UAYtAd/I;ShTIS 01970
TM 978-745-959S•FAN:976.740.98"
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPAN"A FOR ANY EXISTING
STRUCTURE OR BMDIN .
1.0 SITE INFORMATION
Location Name: 13,4 -1525 -;. Ln k)D Building:
Property Address.-
two U -- —- - -- -- -- - - — - - -
4(o
Properly is in a;Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 01A1W E T lZ o 5
Address; a-.5r c, t2 S e-(;.v T /4 y)—a
Gj5V 62L V W
Telephone: 9 ZT( 9 2 7
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation
of existing building New
Bijp1 Description of Proposed Work:
GGivsT lZv,!:-T" TJ O y ;L
-----Mail Permit to: ie1� ma24 a SGf�s�cio r v�v sG ria7� -- --