10 CLIFF ST - BUILDING PERMIT APP ;. CITY OF S.ULEIbi
PUBLIC PROPERTY
DEPARTMENT
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sw&AK wssAnasens 01970
Tm-97L74S-9S"#FAx 979.740.9W
HOMEOWNER LICENSE EXEMP'T'ION
Plea"Print
Date tL D
Job Location I D CiLl `—
Home Owner Address
Home Owner Telephone
Present Mailing Address S42:v3 Ts,
The current exemption of"Homeowner"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowner to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons)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
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EIT'Y-OF LEb
PUBLIC PROPERTY
DEP�IRTMENT
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1.0 SITE INFORMATION
Loaa*M Names C> Cw
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Fropertsl r kxattsA h a;Carrsrvatbn Area YM HWarb OisMlat YM
2.0 OWNF.RWUF INFORMATION
2. Owaer of Land _
Name: -
Address: j-��A2L�
TNephone:
0.0 COMPLETE THIS SECTION FOR WORK IN EYI>l M BUILCINGS ONLY
Addition t.xisting
Renovation Number of Stork! Renovated
Change in Use Nees►
Demolition aw�g
Approximate year of Area per Apar(sQ Renovated
constructlon or renovation
of existing building New
Grid Descdpdon of Proposed Work:
--- —- ---Mail Permit to: - - -
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Permit FN i D EaWnsied Coat X$71:1000 Residential
Eabnood Coat X$W$1008 Canrm v --— —
An,Addtlonal$s.00 is added M an
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Mala woo that an fleWs are PmPwb and *WW w t n to avoid delays in proossdn%
The undeni8ned does hereby appyfWa PerrnK to build to iM(/abaft I
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DateZ _
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