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APPLICATMM FOR
TO
LOCATIW
PEFPMTGPANTED
OF BuapNpg
�I
.4�� . , a CITY OF SALEM, MASSACHUSETTS
Ar PUBLIC PROPERTY DEPARTMENT
120 WASIIINOTON STREET. 3RD F
SALEM. MASSACNUSETTS OOR
QIg L
MAYOR
STAMLET J. UBOVICZ, JR. TELEPNONE: 978F743-9395 EXT.. 380
FAX: 97e-740.9948
HOMEOWNER LICENSE gXEMM0N
Please Print.
Dam f 6 7DoG .
Job Location
Home OWMM Address
HanieOwwTelephoge .74f5- 3l'7 tQ a
Present Mailing Address,:. r
The current exemption of"Homeowner^was WdWAW to include
dwellings of two Unit Of lea and to allow such honim to m° -occupmed
hire who does not Nam a license.provided that the o J�an individual for
supervisor.
DEFIbUTION OF H0MEO{1 M a
Person(a)who Owns a pamd'of land on which he/ resides intends to rea* on
Structures w is,or is to such se be,a one or two family dweilirrlg�attached or detached
than one home ry to use and/or farm stiuctim.. A pew who couskucb more
homeowner"sW Yew period shall not be considered a homed
wriat. Such
,Official, that submit to the Building Official,on a fora acceptable to theuilding
be
Permit responsible for all such word performed under the Building
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
Building Department minimum i understenda the City of Salem
will comply with said nspection edures and requirements and that he/she
Procedures and req ' e
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code �L
9
HO1IH±OWNE1tS �ON
g work for which a Building Permit u
The Code statd "Any Homeowner peen on Section 109.1.1 —Licensing
regWred shall be exempt from the provisions H �en�q a Pasou(s)for hire to
of Construction Supervisors �° shalt act as Supet�
do such work.and that such Homeowner
sor-
sre"assuming the
Homowears who use this axemPtion �a and R�6W O I for Licensing
&Supervisor
eoft in serious
'ruction S of=avj o won 15 lscic of awaten�s o t
s. In his cam Your
problems,Particularly when&a unlicensed person as it woulomeowner bires unlicensedd a licensed
Board camtot as..Perviooc is ultinkav�revonsiible.
Supervisor. The Homeowner
acting
To ensure that the Homeowner is fully aware of hisilm reap a ilitiea,many ca*that
a of the Peewit Application, the Homeowner s issue a
communities requite. msim .ties of a SuP��. On the such a
and
heJshe You may cars to mend
form currently
-f0;;c;jdgcation for use in Your community*
�� 6 I ie I yae t
f CITY OF
SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
4D SALEM, MASSACHUSETTS 01970
9TANLEY J. USOvICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAx: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter in, S 150 A.
The debris will be disposed of in:
Sg T21n Q , (Location of Facility)
Signature of Applicant
Date