1 GRANT RD - BUILDING INSPECTION / �
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- CITY OF SALEM i
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a�` •��'� ,� Date ��
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No. '�2� '�s
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Is Property Located In Location of l
Ithe Histodc Disirict? Yes_No� Building
Is Property Located in
the Conservetlon Area? Yes__No_
BUILDING PERMIT APPLICATION FOR:
Permit ta
(Circle whichever apply) Roof, Reroof stall idin , Construct Deck, Shed, Pool,
Repaid ace, Othe .
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 I
specifications: �
Owner's Name ' (r� / �
Address & Phone � ' b —�`l� 7 �"� ��b S I
ArchitecYs Name �� n ��r
Address & Phone � �
Mechanics Name 4
Address & Phone '- �
,
Whet Is the purpose ai Ilding?
Matedal ot bullding7 If a dwelling, for how many families?
WIII building co i rm to law7� Asbestos? � ���
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Estlmated co � City License # Stat 'cense #
H� �r��nt X
�`' � ign ure Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WQRK BE DONE
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MAIL PERMIT TO: `
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1
No. 7�/D�
APPLICATION FOR
PERMIT TO
Si/��P r�-�eOF �s arE .
LOCATION
_� �/�Ll�NT �� .
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PERMIT GRANTED
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APPROV�D _ `
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CTOR OF BUI INGS 3 .
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CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
;,
I20 WASHINGTON STREET. 3RO FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 976-743-9695 EXT. 380
MAYOR FAX: 976-740-9846
HOMEOWNER LICENSE EXEMPTION
Please Print.
Data `3 1,3 (
Job Location
Home Owner Address
Home Ownta Telephow
Present Mailing Address,.
The current exemption of"Homeowners"was.extended to include owner-occupied
dwellings of two Unit=or leas and to allow such homeoto engage an individual for
hire who does not possess a license,provided that the c w s as supervisor.
DEFINITION OF HOMEOWNER.:.
Persons)who ownp a psrcel:of landon 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 Yew 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 u'
will comply requirements and that he/she
P Y nth said procedures ores4anWuuVmentL
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
HOMgOWNElt3 ly rno
sung work for which a Building Permit>s
that; "Any Homeowner petfo 109.1.1 —Licensing
The Cade states from the provisions of this section(Section
required shall be exempt �r thata Homeowner engages a person(s)for hire to
of Construction Supervisors).Pro
do such work, and that such Homeowner shall act as Supervisor.
tion are unaware that they are assuring the
Many Homeowners who use this excerption Np Q Rules and Regulations for Licensing
responsibilities of a Supervisor 1 15 i lack of awareness often results in serious
Construction Supervisors, ns. In this case your
pmblems,Particularly when the Homeowner Ives unas licensed a licensed
Board cannot proceod against the unlicensed mois ultimat�y
n responsible.
Supervisor. The Homeowner acting as supermbf
To ensure that the Homeowner is fully aware of his/her rebilities,maty
communities require, as a Pat of the permit Application, the Homeowner certify that
the responsibilities ofa. Supervisor. Oa the hurt page of this issue is a
helshe and by several towns. You may cam to amend and adopt such a
form currentlyficat
forrdcertification for use in your community
. .
R
o GIsoIZerot
CITY OR,_SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3010 FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. UsWICZ. JR. TELEPHONE: 978-745-9593 EXT. 380
MAYOR FAX: 978-740.9848
Salem Building:DeRnI en►
_Debris Qkposa_I 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:
tin 4 (Location ofFacility)
Sign Applicant
3 - l3 — dlo
Date