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PL"N PILL OUR LENKY a COMPL UNLY TO AVOID DWAYS.N PRO DUS
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CTfY OF SALEM
BUILDING DEPARTMENT
lio'NMOWNER LICENSE EMAMON
Pkase PM
IOBLOCATION `10 �3v tLAx-
Hot�owrgx ��n�1� .
ADDRESS
TEXPHOMB
p��N'T Iv1AII AiG ADDAESE .
The cwtcaa.uempdon of-bomaxwnc C was exundcd W include a w "Ocwpkd dwcMiv ofTwo
for bire wbo does aot Posen&i
Units a as and m a11ow such homeowwnas to a'baic as individual .
Lan5c pm idcd t Lath.ownei ad b O"T VUW-
DEFDcnow Of HOMEOWNER oa wldeh these b4 orb
Pcnoa(s)who owes a petal of land on which be "resida or irucnd&to Taide. h*tit or b
intended w bc,a one to two family dw-113M eaad><d oT dctarhed od"aot bt:considered
farm suvctures.A pcnon who coTL"n s mmn than one bomc in a two-Y oa form arzsptabk to do
a homcowua. Such-homcow+r' &half submm to the BuBding Of kci4 r br b co9c paaid�
Building Official,that bdshc be Tcsponstbk to sU such work pQfotTsad
The imdcsigned-bomcowntT"asswna rMpow-In ty fot compliancc witb the Stan BuSdiag Code and
other appBoblc goes by-laws.Tuks and teguladcal.
The tmdcsigncd-hoowownaw arnfia that hchhc undcstards the City of Salem Bmldmg
minimum itupccuon prod=and Tcq-d= ms and that Nshc wiL Comply wink said and
Tegammmi
HOMEOWNER'S SIGNATURE `
APPROVAL Of BUILDING INSPECTOR
Sec otbct side for state code
iL
HOMEOWNER'S EXEMPTION
The code sues that: `any homeowner performing wv i for which a buDding permit Is required sball Its
exempt from the pm+isiom of this section (Section 709a.1-ILceosiug of Construction Supervismi);
provided tbat h a homeowner engages a person(s)for hue to do,such wort,that suet bomtowaer slap an
as
Many borneownea who use this aempdon are unaware tbat they are anwring the tzspombpide:are
super dam (see Appcndls Q,Ruler and Iteplatiooa for Vatusing Constauet&m Supervfaom SeedN
.2.24 M bck of awarmm cf icn ycsW f in scrim probltmf,paTDNlaft wben t1K bonmwna bbo
unlivensed perwai In this ease your Board cannot proceed aphM tat mrliecnsed pet p itwtmdd wi&
licensed Supcnisor. The bomeonver acting as suptnisor d uirimatev r IEMS%IL
To ensue that the bcmcowacr is fu1)y aware of hinter respoasrbilitles,many commmtida mqd M.as pant
of the permil application,that the homeowner certify that hehhe mdcstands the responsrb3)ida der
supmism. You may care to amend and adopt suds a forn✓ocnificadw for not in yottr eons
PUBLIC PROPERTY DEPARTMENT
y • 120 WASHINGTON STRUIT, 3RD FLOOR
SALEM,MA O1 a170
TEL- (978)74I6 B" EuT,360
FAX (970) 740.9"6
STANLEY J. 1JSOVICZ, JR.
MAYOR
DISPMAL OF D EBRL4 AFFIDAVIT
In accordance with the pmvidonl of M(l3,c 40,W I aclmowledge that as a condition
of Bnx3 ft Pamit 0 .an debris Maims from the dam activity
govemed by this Building Permit shall be disposed of in a pmopaly Beewed aDH&wuM
disposal LmhW,as defned by MUL c I M SIXA.
The debdo will be disposed of at:
Loco"ofFaeilky
SigoabuiofPamitApplic ut ►
FULLY complete the foilowiog infnmation;
(PLEASE PRINT CLEARLY)
)i L4 t
Name ofPamit Applicant
Firm Name,if MY
Add<ras.City k State
The above statute requites that debris from the demolition,rarovsdM rebab or other
altaation of building or structum be disposed in a properly-licensed soH&wsate disposal
5cik as defined by MGL cIM Sl9QA,and the building permits or>icatses are to
iadieate the location of the facility.