14 FRANCIS RD - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
Klavc�,
MAYOR 120 WASHINGTON SI1F8r•UN EM SIASSACHUSEriS 01970
TEL.978-73S-9S9S*FAu 978-740-9&M
HOMEOWNER LICENSE EXEM"ION
Please Print
Date 7-1d,- Q7
Job Location /Y Frp n/C;-S aQ9
Home Owner Address %4 Ae)i/?C-,5 k.D
Home Owner Telephone 7 7€'- 7 _5-- C3,9 �
Present Mailing Address Fo-N N e_c• R D— 5 41& aq m A
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.
DEFlN PION 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 "homeowne► '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.
HOMEOWNERS SIGNATURE —
APPROVAL OF BUILDING INSPECTOR Z
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
%1.\ 12C W.\sIItVC-:OM$CREET #$AU%1,MAIS.u:'It I IL1 IS:191^-
TF.1:978-743-9595 #FAx:978•74G9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ .. 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 MGL c
111. S 150A.
The debris will be transported by:
— — (name of hauler)
The debris will be disposed of in
(aame Of facility)
iad.i ts� lif(uciLly)
♦i_.:LIUCc >f :CCI1llC.(:(LIC 1.lt - - _
-4ta _ .
G. . C . Land Surveyors. Inc .
7 WINTER ST. SUITE, 3 PEABODY, MA'. 01960, (978)531-1191•FAX (978)531-5501
CEC .
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REFERENCES
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I HEREBY CERTIFY THAT THE FOUNDATION SHOWN
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` PUBLIC PROPERTY
DEPARTMENT
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AM ICATION FOR THE REPAIR, RENOirATt; N CONSTRUCTION
ITI DEMOLON, OR CHANGE OF USE OR .& I> W& FOR ANY EXISTING
STRUCTC � OR BUILDIN
1.0 SITE INFORMATION "
Location Name:
Property Address: __ _ -
I Nc,, s R
Propwty is 10Ceted In e:Conservation Aron Y/N AJ_Histode District YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land 1
Name: 5c0 Ge��4
Address /`l
Telephone: 978- �
3.0 COMPLETE THIS SECTION FOR WORK IN EYIATiNG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
96ef Description of Proposed Work:
Add roi� M�l�✓ �vv�
-Mail Permit to: -
5`N9Jf
What is the current use of the Building? __�
n �l 1�4m-2� if dwelling,how many units?___�-
Matwisl of Building? Asbestos?
wo the Budding Conform to Law?
Architects Name
Address and phone
Mechanie's Name
Address and Phone HIC Registration 0
Construction Supervisors uCee
O Permi/Fora Clrx a +islbn
Estimated Cost of project S Estimated Cost X S7/$jOOO Residential
permit Fee S
- - ------- --
Estimated Cost X S'l '006 CarnmerGat --
- An Additional $5.00 is added as an
Administrative charoe•
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building permit to build to the above stated
spspecifications. Signed under penalty.of periury
Date �-�a
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