72 HATHORNE ST - BUILDING INSPECTION (3) o�
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IQR AMC GRANTED
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CITY OF SALEM�
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BIIILDOrG PERMIT APPLICATION FOR:
Plank to:
(Grow WhlohaW 4pply) Roof Rnoof, Install 81di1 Dsok, ShwL Pool,
RoPaTloplaW Olhw:'
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS N PROOBBM
TO THE INSPECTOR OF BUILDINGS:
hwoW apples for s pomik to taadld &own" to on foie.... a0
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OmWe Name Jc g A+ V&(r-a hm
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Mohkwft Name
Address & Phorm ( =b
M aolankes Name
Address A Phone
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glawre of Appk@M
SON�D UNDER THE I "*.I'
OF PERJURY
DESCRIPTION OF WORK To eE DW
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MAIL PERMIT T*6,, /�D
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401
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MIL-
CITY OF SALEM
WADING DEPARTMENT
HoNEOWNER UCENSE EMO110N
Pkase PM
DATE 20
IOBLOCAT70N �2 I-IA'�horN� S"F
HOtr>EOWI�A Z. N p 4HoCu P�
- -----------
ADDRESS
HOMEoe ti - 41-3 6 l to ' ---------------
TELXPHOW
PRESENTMmLwrjADDRESS 72 I�rt��oe'��ST
The C=co cxcmpuott of bcu=wocTC was emended to include pwnct gcempled ds dllags d7Wo
Units a kss and w rJbw such MTBtOw ras w en jsgt on udrMW la hao who does not Posaes tl
heatse,.proyided tbastht Owmw act 82 NJPC'vlwi
DEFT MON OF HOWOWML* mm w44th that h a h
Person(5)who owns a parcel of land cs which bdshe resides a intends tm*t s >me and/Ot
intaded w bc,s one to two family dwelling,anadod a detached structua oda tool be cousklad
farm svoeavcs.A person who consovns mac than one home in a two-y Pc'i
Such'homeow nd shop svbndt w the Building 0Mcizi,on a form sampabk tm*4
a bmwmaa. asibk to an sudr wotlr paformed wader t a Pam
Building Offie4 that he/she be rupo
The undasipcd-bomeowner"assaana MYOTLnbility lot compliarre with the Stan Building Code tmd
other applicable jots by-lava,toles sad tegmlatiome
The tmdasi jncd"homeowner"=IIba that he/she undasmrds the City of Ss�
Bw
minimum inSpClion pmccducs and rngtmcnunts and 1191 Nsht will comply
tcquinstcmL !J�
HONffiOWNER'S SIGNATURE
APPROVAL OF B=ING INSPECTOR
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Sec other sdc for state code
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T
HOMEOWNER'S EXEMPTION
The code states that: 'any homeowner performing vmjk for whieb's binding permit is regnhed sball be
cXcmFA from the prorisiois of ibis scction (Samoa 31VAa-1Lccosiog of Counruetioo Supervisero
Provided that is a bomeowner cngaga a person(s)for hire to do.such wwk that sud bomeowaer tivin trot
as sipaviSM7
Mw7 bomeowncs who use this cxcm don we imawarrthe they are Lamming the tespvmt'E Bdes da
supervisor(sec Appcodh Qi Rults and Regulations for I.iecosiag Coostruetlen Supervbom$=bias
.2.2M. This lack of swa=wn often nsdu in serious probkms,pardcolaiV when the homeowner bbaa
uriliccnsed pers mi In this case yom Board eariwt proceed agahm the w0cc ued pergon as it world wad
licensed Supa+isa. The Lomeowtocr acsiag as sopervbor is uhiaaase�r rn�oo;ibis, .
To assure that the homeowner is telly aware of hV=mspotLnbilitks,many evannmddes regkdm as past
of the pmrii application,that the borneo vner cenify that hclshe undaswrds the responsiibiNsTa eta
suptTAM. You may care to amend and adopt sou h a formJcenYi atioo Aw tsse is your comsoaft
Puouc PROPERTY DEPARTMENT
\ 120 WASHING.TON STREET, 31RD FLOOR
SALEM,MA 01670
TEL (E78)7434595 Orr.380
FAX (07e) 740.9646
STANLEY J. USOVIC2, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
III amoidaace with the provisions of M(X c 40,S34,I wlmowledge that s.a camditiou
of Permit ti
gov�this Building Permit sbafl bed' mowd u m the edy lic teed activytl,
digosal facility,as del oed by M($,A�c�/IQ SISQA. of inartprDperly liceoaed solid-wasoe
The debtiswrtibedisposedofat E ( a-rf,/IP 5:14 Psco
Locatlml ofFacMy
-.ii-r., Q
Slgoadue of Pemrit Applicaa� Defoe
FULLY complete the following inSarmatiom. i
(PLEASE PPJM CLEARLY)
Scc(-I- f.�u�7�LE2
Nave ofPermitAoliew
Film Name,if any
'Z)- 906v-ug 5 T Sa1�
Addnp,City&State
The above statute requires that debris fin the demohtiM Movation,rehab or other
alteration of buildmg or stnlcauo be disposed in a properly-licensed soli&wEate
&Uty as defined by M(X cIII,SISOA,and the building permits or liceoaea are to
Mute the location of the facility.