15 FOWLER ST - BUILDING INSPECTION R I
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CITY OF SA.EM
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TO THE INSPECTOR OF BLNLDINOS:
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PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON 6TR[aT, 3ND FLOOR
6AI M,MA 01 a170
TEL (276)745-6565 EXT.860
FAX (676) 7406646
STANLEY J. U60VICZ, JIL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the pmvisione of MOL c 40,S34,I acknowledge that as a condition
of Building Permit g . an
debris resulting from the constacbon activity
governed by this Building Permit sball be disposed of is a properly licensed sokid-wu%
diapoeal facility,a degued by MOL c EL Sl ak
The debda will be disposed of at:
Location Of Facility l
S4Fwas of Permit Applicant Date
PULLY complete the following in* m um
(PLEASE PRINT CLEARLY)
Name ofPeamitApplicant
Firm Name,if any
16
Address City tit State '
The above Statute requires that debris from the demolition,renovation,rehab or other
akmdon of building or stnictwe be disposed in a properly-licensed solid-waste disposal
facility as de Tined by WX cIII,S150A,and the building permits or licenses are to
indicate the location of the facility.
aty OF SALEM
BURDINGDEPARTMM
xONMOWNER LICENSE DMOT1014
Please pm
DA7E 2 0
IOBLOCAMOK � '�—
HOkffiOWt�A •
TELEPHM
' ADDRESS
PRESENT MAII.R?G ADDRESS
The CwTant o n
cmpdon of"homeower"was C=Dded to include owvero=' Vkd dwd0ap d7yV0
Units a less and W show such hornwwnas to C4W on individ»a1 fas bin who does nol possess a
li«usc,,previded dmthe own"set as supccviaor.
DEnNMON OF H0WCWNML*
Pcrson(s)who owns s pwzd of land on which bclshe MWO or Wands to reside-on Wldeht
intended m bc,s one to two JwrMy dwelling Mched of dctadted 0=0'" od q t trot be cos ndeted
farm swacumL A person who constructs mart than one hams at a two-y pu
a bomcow•ner. Such'homcoa'nd shalt submdt w the BuDding Offiaal�on a form aCaptabk b rice
Building Ofrici4 that bdit be tcspombk to sll suds work performed u dcr dtc bnlldng PmlldL
71tc undersigned`homeowner"sssurnes tcsporL�btltry for Compliance withthc Stan BnDding Code tmd '
othu appGcablc goes by-laws.nines Md UZWR16WL
The undersigned`homeowner"cmiiBa Lbm luhhc undoawrdsthe City of Wan BwWzgDeparoaft.
n=mwn u ap=on proccdurss and cal ' cos that kjft will Comply with said prvcc t and
rcgwremcgL
HOMEOWNWS SIGNATURE
APPROVAL OF BUEDING INSPECTOR
Sec other sde for state Cade
e
HOMEO"ER'S EXENEMON
The code state that• `any homeowner performing-,ivA for svhicb a building permit is regaaed sbal be
exempt from the prmisiow of this section (Section 71J1.2-Uaosing of Construction Superv�
Provided that is a homeowner engages a person(s)for hire to do.such work slit Fad boumwau 44 am
as sqcrvisw�"
Marry bomcowncts Vito use this exemption we W"Mw•afi that they are anumiog the usponsumes Ica
n7crrisof (nee Appcodis Q,Rules and Regulations for Liexosing Coosssvc*m Supervisoes,Se=atw
.2.24 This lade of awareness ollen urdu in scriow problems,partica"when the Wmiowncr bitaa
unlicensed persc= In this case your Board amtot proceed sgsinst the=Wccrosed persona as it WOO aim
licensed Supcnisa. The hom m-ocr suing as supervisw Is uidtustely sssrvsibh,
To ensure that the homeowner Is fully aware of hither r esp=nbiNes,marry eoaunmddes tegolm.as peat
of the permil appliatioq that the homeowner certify that hclshe tudasnerds the sesponsibiHda ofa
supervisor. You may ore to amend and adopt such a form/ctnifiation for use in your coummaW