24 CLIFTON AVE - BUILDING INSPECTION (4) ..1
CITY OF SALEM
4D Cal-O PUBLIC PROPRERTY
DEPARTMENT
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To:97N45-15% F.\x:9M?4C."*
Construction Debris Disposaf Affidavit
(required for all demolition az work)
renovation
In accordance with the sixth edition of the State Building Code, 7S0 CNIR section 111.5
Debris,and the provisions of M. GL a 40.S 54;
Building{Permit N - I _ is issued with the condition that the debris resultinil from
this work shall be disposed of in a properly licensed waste disposal facility as defined by v1GL c
I L t. S 1.50A.
The debris will be transported by:
I /
(lmme of cuter)
rho debris will be disposed of in :
(114me ui fatiGty)
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CITY
C OF SALEM
PUBLIC PROPE
RTY
DEPARTMENT
Kl\WFJl.6Y Dew•ry.
MAYOR 120 WASmNGTON S wEr•SALEK%L%s&AOtusrm 01970
71:1_978-745-959S 0 FA%:978-740.98"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date P,-- 20 r-C) —
Job Location e—l,,
Home Owner Address c�S�
Home Owner Telephone —
Present Mailing Address L
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
j 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 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`ry-oF
PUBLIC PROPERTY
DEPARThIF.►�iT
I
120 WAUUNGTCW SMFAT•yMA;W MANACKLSh-1n 01970
f TM.9 ?4&2S"•FAS 970.74048"
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
-- -
Property is located in a;Conservation Area YIN A b Historic District YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: L� C1 �cr1
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN FYINTrNG BUILDINGS ONLY
I
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building (j�� r New
Brief Description of Proposed Work:
-Mail Permit to: ' r �G
What is the current use of the Building?
Material of Building? ('^ R' � rJ if dwelling.how many units?__._— .
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Construction Supervisors License# __ HIC Registration#
Estimated Cost of Project S� permit Fee Calculation
Permit Fes i 5 `�5 Estimated COsL X$7/$1000 Residential
-- - -- - Estimated CostX$1V$1000 fommerclaii ---- --._ _ -.
An Addibonsi $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 a above stated
(IM
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specifications. Signed under penally of pellury X
Date
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