3 HAYES RD - BUILDING INSPECTION I
I4ARPS MU TI3E fi0m� APPROVED BY T*IE
LN5PEXTPR PRWR TP A PERMIT BEJNG GRANTED
CITY OF SALEM
Date
Ward
�7 • T
Zoning District
Is Property Located in Location of
the Historic District? Yes_No Building hti,-eS 4a.z
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair Replace, Other:
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
specifications
Owner's Name Y � C I S +JI o NN r I
Address & Phone 3 HAy _Rf�. 192h -)q4 •13 3(,
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone ( )
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost 'r aop City License # State License #
Home Improvement
I3
c. !
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
No.\ -%
APPLICATION FOR
��PERMIT TO
!%C c °Cn
f
LOCATION
3 ll5hv s �� l�
PERMIT GRANTED
�IFJc� 19
AP OV�D \
I SPECTOR BUILDINGS
i
CITY OF SALEM
BUIIivri DEPAPamm
HOMEOWNEPLUCENSEEXF OMON
Please PAN
DATE G -a7•-a `�
. HOMEORII�R 3 f S
ADMM
Hrn„¢o�vrmt (9 e } -)qN• ??
PRESENT MAII.II?G ADDRESS 3 H w Y as-
The Q Il
cs cf"bomwwncrs"was c=uded w bclude owocroeeupkd dwslYep dT9M0
• avmd.cxcmW �bye avLo does not possess t1
Uniu a leas and so allow'such homcowwM to cngagc @A bav'&
L=w,Vw4dW*M.*a*wow see as supervims
DUVaTION OF HOT&OWML
Pcrson(s)who owns s pwccl of Lad on which brJshe resides m irucnds to reside,ou w♦defi 4 �
intaded to be,s one to two family dwclling,ansd>ed of dctadwd strucma t+otbe e�nndoad
farm suucwm A pcsan who const=rrwrc than one home in s�y al s!�s�abk tcont
s yoding 0M. Such`lwmoow c po bsub o am Rcb work performed wAat the bmDft paste
Building Offuial,that yclshe�' .
The tmdasipW-bomeowna"assumes respombft for comPliw"w1*tlfic State Building Code sad
othcr applicable goes by-•1aw4.rules and Tcguls>wot
The tm WTcd"homwwc>d
oatibes t w WaK undcraruds the City of Ssk=Building Depw=nK.
minimttm irespcvon prazdur�and yu') curcms and that hlshc will wmply w+t1t 1
ooeftes sad
T�
2�LHONIEOWNFR'S SIGMA
APPROVAL OF B=ING INSPEC rOR
See otba side fm SM code
HOMEOWNER'S EXEMPTION
The code suta 112 C "any homeowner performing Murk for wWcb a buD tg permit Is requb slap ba
csempt from the yrO&ions of this sccdon (Section Ilaa-Lansing of Coustructittn Superdwro
Provided that is a bomeocrrter cngaga a perwn(s)for bhe to do.such work tbm aircb hvmcowtaa dM an
Mara borneowma wbo use this cntmption arc iamwax rbu they are asamubg the eta
svpmisor(sec Appcndla Q,Ruin,and Regulsrioos for I.iccming Construction SoPesrbors,Seesiaat
• .2.13} 7'bis lack td avrarcrtess often results in serious pmbkms,partieu>srir when Iba hom'.vwner Mnf
urJkmsed persons. In Ibis can yaw Board a mot procood agaam the tmliaemed paion as k wtruld Mb
licensed Stryrnisa 710e bomcon'ncr acting as apervbor is otdaaat*resEmlip b
To eusum that the homeowmr is fully aware of hi&a responn'bilitSa,mwW oommmddu tegtdm.as pat
of the perms{application,that the homeowner ocnify that lKhhc um&=arda the tesponsibiNdea at'a
supavism. You may cart:to amend and adopt such a brmlcenV=d m ibr use in yom coautinniq,
x PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 9RD FLOOR
SALEM,MA O 1970
TEL. (978)745-9595 EXT. 360
FAX (978) 740-9646
STANLEY J. USOVICZ. JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MCI,c III, S 150A.
The debris will be disposed of at <�p L r1 rM1�iu �fi R `CI g�r an
Location of Facility
Signature of Perant Applicant/ Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
/ KflNCIS a IL �
Name of Permit Applicant
Firm Name,if any
-3 NAYFS i 1b - j Ch j 1�AsS ,
Address, City&State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL CIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.