0007 BERRYWOOD LN - BPA-2008-401 PELLET STOVE �1
CITY OF S.3L.EM
PUBLIC PROPERTY
- ��j�-DEPARTMENT
130 WMMNCMN snraT•S ,� eu,�1MSA00.'Sh-1TS 01970
7Fj:978.74S-9S"• FAX 976.740.""
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location
Home Owner Address 7 t3i<P w�D L.tR me
Home Owner Telephone `i 78 - 7 y o • ',7 i3 S
Present Mailing Address 6iarnry'--
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
"homeownee'shall submit to the Building Official,on a fora 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
EI'I'�l-OFr -
PUBLIC PROPERTY
DEPARTMENT
�lAvaa 130 WAsHu4cr N 5itsw•Swt&K wsuansrra 01970
TM:M745-9M•PAZ 9711•7404 M
APPLICATION FOR THZ REPAIR. RENOVATION. Cor4STgUCTION.
D&MOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILD G
1.0 SITE INFORMATION
Location Name: 9uildl v
ftop" -- ------- y�- -- - -- -
7 9��Y �0o D L
Property Is located In a;Conservatlon Arse YM ,(7L Htslaric 0wwct YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ►}12-v— + L I
Address
-7 �7 �12�t�pdD L-l� c
Telephone: 9 7 g - 7 y O - S f
3.000MPLETE THIS SECTION FOR WORK IN EKlSMXQ BUILDINGS ONLY
Addition PNew
Renovation Number of Storie
Change in Use ��
Demolition
Approximate year of Area per floor (sf)
construction or renovation
of existing building 3
Brief Description of Proposed Work:
�T� I � �c Llt I s1"at7E I h5c�-1
--------Mail Permit to: ---- - -
r
What is the current use of the Building? r ovti£
Material of Building? .uoo 17 if dwelling.how marry units? i:- J
Will the Building Conform to Law? Asbestos? -
Archileas Name
Address and Phone l 1
MedwanWs Name
Address and Phone
Construction Supervisors license 0 HIC Registration 0
Estimated Cost of Project: 000• pm*Fee Calculation
Perm Fee: y Estimated Cost X$7/$1000 Residential''
Esdmated Cost X$41/411000 Commend
An.Additional $6.00 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 eta
spwftaftm. Signed under penalty of Perjury /! "' � v`�
Date 07
N
S
06 a