10 FOSTER ST - BUILDING INSPECTION CITY OF S�kLEM
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXE.MMON
Please Print
Date q z t9
Job Location 10 P krgeL Sv - � E r� />,1/� 0 )1,10
Home Owner Address ID Gosh¢ S,r .
Home Owner Telephone 9 -t K- S S 4 - S`IS G
Present Mailing Address to ram Sr- S,t e r m AU o 111 e
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
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
E HOMEOWNERS SIGNATURE off- P
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
SW •R 12C W.%al,4W::. S RW•S.%L;Sk {'la::91:
Construction Debris Disposai Affidavit
(required for all demotition and renovation work)
in =onlanec with the sixth edition of the State Building Code,7S0 MR section 111.3
Debris,and the provisions of M. GL c 40.S 34.
Building Permit 0 _ . _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by.%1GL c
t 11. S 130A.
The debris will be transported by:
CAaVNt;
(name of touter)
me debris will be disposed of in :
h,arne otiac,Aty)
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PUBLIC PROPERTY
DEPARTMENT
%IAVM 130 WASUNGUM lMM 0 sALUk wsuaa:sr„s Ot97o
APPLICATION FOR THE REPAIR. RENOVATION_ CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUIL3ING-
1.0 317E INFORMATION '
Location Nance BuildkV
--
S'� 0
ProWV is kxwted In a;Conservation Am Y/N mistaft owoks Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: -rAOMAS '1�ou'
Address: (0 Fo S f er- S,-
C iA LE'r^ r1A
Telephorw. `j'16 834- -S`1S&
3.0 COMPLETE THIS SECTION FOR WORK IN EXUKr yL; BUILDINGS ONLY
Addition Existing 2-
Renovation jd Number of Stories Renovated
Change in Use New
Demolition Existing i (p 00/
Approximate year of Area per floor (sf) Renovated
construction or renovation [ROD
of existing building New
adef Description of Proposed Work:
Sr21W h KG�26�}t SfY2vC�UrL6
-- —Mail Permit to; (t1wAAv toyLz 10 I-osT2 fl t',22 W6¢ OR,,0 - - _.--
what is the Current use of the Building? 2
Material of BuiWtrrg? If dwelling.how marry units?
? Y
S Asbestos? N e
� Conform to Law? .
wi �
AwAiteas Name
Address and Phone )
Medm%Ws Name
Address and Phone
Construction Supervisors License 0 HIC Registratbn N
Estimated Cost of Projects 2()(P Permit Fee Cak bdon
Permit Fee s Estimated Cost X$7/s1000 Residential
Estimated Cost XSil/5100000Mm"clat-<--------__ _ ..
An Additional $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 far a Building Permit to build to the ab s stated
specillcatkons. Signed under penally of perfury
Date Z 0-1
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