165 FEDERAL ST - BUILDING INSPECTION (3) Aid T-BE f&*B-0110 APPROVED BY T+IE
.MPECTD-R ,PRWR TO A_PERMIT BEING GRANTED
CITY OF SALEM
"N
No.`rzo ``� ?� Date / Q
� Y11NE.
Is Property Located In Locatin of
the Historic District? Yes No Building � r
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: SHE zpeMeic,
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications: ��
Owner's Name ADD
Address & Phone /6$ PC fi
Architect's Name
Address & Phone L 1
Mechanics Name
Address & Phone I 1
What is the purpose of building?
Material of building? If a dwelling, for how many families?
WIII building conform to law? Asbestos?
Estimated cost Say City License # IJ A State cen e #
Home Improvement
Lie. i
I nature of Applican
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
i
No.i`' =�—`��
APPLICATION FOR
PERMITTO
lo
q�a zw
LOCATION. �/ // — ���✓�
PERMIT GRANTED
APR�VFD
INSPECTOA OF BUILDINGS
CITY OF SALEM
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please Prim
DATE /D / 03
JOB LOCATION
HOMEOWNER Sd"'
ADDRESS
HOMEOWNER 9 74"/' �
TELEPHONE
PRESENT MAILING ADDRESS Sffn�
The cement 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 hire who does not possess a
provided that the owner act as supervisor.
license,prop
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 to 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 to all such work performed under the building permit.
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and
other applicable goes by-laws,rules and regulations.
The undersigned"homeowner"certifies O'ath the City of Salem Building Department
minimum inspection procedures and req ents t sh comply with said procedures and
requirements.
HOMEOWNER'S SIGNA
APPROVAL OF BUILDING INSPECTOR a
See other side for sate code
HOMEOWNER'S EXEMPTION
The code states that: '`any homeowner performing work for which a building permit is requited shall be
exempt from the provisions of this section(Section 10.9.1.1—licensing of Construction Supervisors);
Provided that is a homeowner engages a person(s)for hire to do such work,that such homeowner shall act
as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the tesponstbilities of a
supervisor(see Appendix Q,Rules and Regulations for Licensing Construction Supervisors,Section
2.15). This lack of awareness often results in serious problems,particularly when the homeowner hires
unlicensed persons In this case your Board cannot proceed against the unlicensed person as it wvtdd with
licensed Supervisor. The homeowner acting as supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of hi/her responsibilities,many communities require,as part
of the permit application,that the homeowner certify that he/she understands the responsibilities of a
supervisor. You may care to amend and adopt such a form/certification for use in your community.
•
OF SAL.EM,- MASSACHUSETTS
Cow e PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
$ALEM,MA 01970
TEL. (978)745-9595 EXT. 380
�Gna FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition
of Building Permit# all debris resulting from the construction activity
govemed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c IIL
S150A.
The debris will be d' /�LtS�OC vi H �ifl'
Location of Facility
11,46 of Permit Appli D
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
itILA-R)c, L4 L QNtF%P--
Name of Permit Applicant
Firm ame,if any
IAs ) l7m --311- /nA OIg70
Address, City&State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
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