4 FEDERAL CT - BUILDING INSPECTION i+
AM BGRANTED
CITY OF S4EM
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EUILDNO PMW APPLICATION POR:
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PLEASE FILL OUr L KMLY a COMPLETELY TO AVOW DELAYS IN PRn oo@Wa
TO THE INSPECTOR OF SLALOINOS: `
The
hmW oppft6. for a pw t to buld CoolA to uw foim...
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CTPY OF SALEM
BUIIDINGDEPARTIv M 014
HOMEOWNER LICENSE DOOM
Pkm Prime
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_ IOBI.00AnoN `- Fe���al Co�� t .
HO► Owrmt
ADDRESS
'HOhdEOWtlsl 9 --? 8 7 �O
TELEPHONE
G ADDRESS l �1 !
PRESENT MP.>LIt•? 2 '
w
on of"homeowners"was c= ded to i=ludc owoeroewpkd dwclGep dTVllp
7]rc cmrad. re bo dos sot Possess a
Units a less and
d t to o allow such)mores to mbaie an u1Im bin
]iea►se,.p vvkkd*X iba owaar ad as surer&w.
DEFIRMON OF HOIdEOWML
Person(s)wbo owns a parcel of land on wWch he/she raid=or intends to*aide+on wh hh*I&or a
inirnded w be,a one to two fatnDy dwelling,anactd or dcradted swcima od sbaD tool be eoasidaed
farm mucwmL A person wbo constructs mmt than one home in s two-y Pat
a bomeow•na. Such`hommw'rect' sh_X anbrsm w the Building Offid4 on a loan a=gtmbk to*4
Building OMe4 that best be rsspombk to all sods work pdfonned mdaf t w hMdmg Pa=
The undcrsipmd-bomww=r assta us tesporu''b'ilk for comPru=with the Stau BaDdiug Code w d
other applimble goes by-laws,roles and mgnlatSWL
Tt tmdasigned'hocKaw reet"cau5cs that hest undw mn&the City of Salem BA%g DepwvwK.
minimum maps»on FD=dma and rcyuircmcros and that hest will comply with said pioadtna sad HOIaOWNWS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
\ Set od=sdc for state code
L
HOMEOWNER'S EXEA'MON
The code states that 'any homeowner performing work for which a building permit is required sbaL ix
exempt from the pmmions of this section (Section 109.1d,-liansiog or Constructko Suptrviwsio
Provided that is a homeowner engages a person (s)for hue to do.such wmk that suet homtowatr a"am
as
Mara borneowrers who use this exemption art imaware that they are assttmim the responsume:ata
ngxrrism (set Appeodla Q,Ruins and Regulations for l.icnoiog Construction Snperr{sors,ScC*m
.2.24 This lack of swanness often mutts in serious probkms,partievhtrb wben tht bomeowavbbU
unlicensed persoas. In this case yow Board camat proceed t:Saimt tht tt iScenxd person as k wostld widt
licensed Svprnisar. Tbt bomoonwtr*cling as auperv6m Is vWmats!y rtsEmslbiL
To cutest that the homeowner Is fully awart of hiAer responsibilities,ruany commmtide tegdm-as peat
of the permi4 appliodoq that the homeowner ccnify that heishe tvdastands the rssponsibllida ofa
Supervisor. You may cart to amend and adopt such a 1cmdechificatim for on in yam eoanmmW
!" PUBUC PROPERTY DEPARTMENT
120 WASHINaWN STRELT, 3RD FLOOR
SAL[M,MA O t S70
TEL (276)745-9656 ExT.360
%W FAX (076) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRLS AFFIDAVIT
In accordance with the provis"Ont of M(X c 40,S34,I w1mowledge that as a condition
of Building Permit ti .all debris resulting from the ommmctio n activity
governed by this Building Permit shaft be disposed of in a properly licensed solid-waste
disposal pity,as def$ned by MOO c B%SIMA. ,\
The debris wM be disposed of at
Location of Facrluy
Signadue of Permit Applicant
FULLY complete the following infonaation:
(PLEASE PRIM CLEARLY)
Name of Permit Applicant
Firm Name,if any
Address,City dt State
The above statute mgmma that debris from the demolition, mcovation,mhab or other
alteration of budding or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL till,S I SOA, and the building permits or licenses ate to
indicate the location of the facility.