2 BORDER ST - BUILDING INSPECTION f�
-PkA"6i WT0E AAA'rMIB OVER BY T44E
JdSPEL7L�A 1 1pA D .P. Will GRANTED
CITY OF SAL.EM
No. cw\ -�J J -� : . Date18 ft0p"Located in
of
Yek_No V Ina 601QP6Y, sT.
Is Property LocWW in
the CoraenNlgn Area? Ycs_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, struct. Shed, Pool,
Repair/Replace, Other.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCR$ MO
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the folW&Ing
specifications:
Owner's Name eydwD I. MWDoQCA
Address & Phone 62 904Q 2 1 --p6-39q-4
Architect's Name cry- KU6-6L /K%uLS Cal' r UCrt W
Address & Phone SAI MA-. I I
Mechanics Name
Address & Phone
Whd is thepurpo wa bu
LUNW of tw~_ Wb o D N a MmOV,for how many kmlu?
x
NAM bukkV cordorm to law? MbWw? -h
t OWWedw. *56 , °- Cpy uowm r fV A state Uow"•
8 �C
0 acre reproe.nc
Lie. /
Signature §f Applicant
SIGNED UNDER THE ' „
OF PERJURY iN
DESCRIPTION OF WORK TO BE DpNE
t ��D �lX12i MK oPF sty6- of- Ole Ij
•
i
1
u' MAIL PERMIT TO.•
•n:...
WE .
s
molgE
APPLICATION FOR
PERMIT TO _
LOCATION
PERMIT GRANTED
APPWVfD a� �
INSPPECT( OR OFvBUII/L,DINGS
:,y
r
# CTTY OF SALEM
BUILDING DEPARTMM
BOMEOWNER LICENSE EMOTION
pkasc prfml
DATE a 0
JOBIDCAM SAti�M
. HOMEOWI�R � lN��J� SI .
ADDRESS
TELMONE
PRESENT MAILING ADDRESS �
The nmW.L[cmpuvn of-bon. awneis'was e.[hended to m'cllu_d1eJOv' Te ocmplcd dwc=f p c(TWO
llnita'Ot less aitd l0 allow al7Cb bomevwtKrs t0 atgage an tndrvtdua)�1Nt A'b0 does Tnl poaseat 1 .
hccnse,.Fcundcd 6m the owes act as supervisor.
DEF KmON CF HO)aOWNER
Person(5)wbo owns a pm=l of land on which hclshe sides or intrnds 10 reside,on whkh >s
intended to be,a one to two family dwelling,attached of detached sm cror s>
Win suvcwm A person who comtntcu mote than one home to a two-year period shall ma be eonsl6cmd
a hou=wna. Such`home*A7 d ahall'subttdt to the Buulding OJJicial.on a form atxxptabk b tls
Building Official,that Wshc be nspon%bk to all such work pafonmed a da the bmldwg pauk
The undersigned'bomcvwna"murnes rcrpmribility for compli>nhcc with the Stan Building Code sad
othu appliablc goes by-laws,rules and rcgulaticM
The hmdersigncd`hotneowtter". act zi5a 5ta
that lulshe undethds the City of Salem B nildmg Departroml.
minimum vispccvon proccdurm and ngViirc=nu and that Nshc will=nVly with said proeedwa and
requirmcaL
HOMEOwNWS SIGNATURE
APPROVAL OF B=ING INSPECTOR 2!2L�
Sec otber side foi Stall code
HOMEOWNER'S EXENEMON
The code states ftL `any bcn=v ncr performing work fm which a bulldmg permit is req»ued shall tt
exempt from the provisions of ibis scenon (Section 3Qy11-13censing of Conaruetion Suptrv6ori)j
Provided that is a homcwmaa engages a pctaon(s)fot hire to do.such work,that sueb bomeowaa der ad
as supavism:"
Marry b nwowncrs wbo use this cnmpdon we unaware tbat they an assmning the tespoms%D**mu CC&
supervisor (see Appcndis Q,Rules and Regulstions for Llecnsing Cooaruetiou Superrisors,Seeds♦
.2.14 This lack of awareness oficn rcrOts in serious problems,parccub aly when the homeowner WM
un1'xmrsed pen= In this case yom Board cannot proceed&&abut the wtliocased pawn as tt would wig
licensed Strpmisc�r. The bomeowner aaiog as superv6or b vWwate;y rssrmslbM,
To ctuum that the bomeowner is filly aware of M4=respon_s-biDties,many c mmw ilia reqube:as past
of the perrrtit sppl'reetim that the homeowner ecrdfy that W&hc turdo um&the responsbitlaes ofa
supcnisor. You may can to amend and adopt sui b a forzWcc•t>ficatioo for rose in ym co=tmlV.
W PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL (978)745-9595 ExT. 380
FAx (976) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit# , all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III, S150A//.
The debris will be disposed of at: 4/Q z,c(e. (4�i
Location of Facility
OBI
Signature Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
F—Rj pq 5. He-WD )CA
Name of Permit Applicant
Firm Name, if any
Address, City&State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.