394 ESSEX ST - BUILDING PERMIT APPr
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXEIMMON
Please Print
Date 8/S ZOa�
Job Location 3% �S� ovii Z d
Home Owner Address as as e- 1<
Home Owner Telephone G7l " v6�q q?Z614
Present Mailing Address 5V S0.tew. iNv-\ Olq-jb
4 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
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 _ _ 45G��
APPROVAL OF BUILDING INSPECTOR
See other side for state code
" BLIC PROPERTY
C
DEPAR'I'11dENT
I mWALEV ORMCL)LL
MAYM 130 WANUNGM14 h MM•SNrJ;MAMOHmns 01970
TEL-976715-MS•FAx7 97s.740.9W
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDIN .
1.0 SITE INFORMATION
Location Name: Building:
--- - _
Property Addresw: -------- — ----- - - - _- - ----
Property is Located in a;Con"matlon Area Y/N Hst ft Dhaka Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: 2�/' eyr �e v ti �w 6\cl7c?
Telephone: �$ 5oq gSzj/4
3.0 COMPLETE THIS SECTION FOR WORK IN E7(lSIiNG BUILD ING 8 ONLY
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 New
add Description of Proposed Work:
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-- _----Mail Permit to:
What is the current use of the Building?
Material of Building? If dwelling.how many units?
Asbestos?
Will the Building Conform to Law?
-
Architect's Name '
Address and Phones
Mechanic's Name
Address and Phone
Constriction Supervisors License 0 HIC Registration ft
Estimated Costa �f P1� Pe iG e Calculation
Permit Fee .jsJ•� Estimated Costst X i7/51000 Residential
-__-_._ - ._ -- -- -------..-- — - - Estimated Cost $11/51000 Commmc al----
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury -
Date 41 2�
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