15 HIGHLAND ST - BUILDING INSPECTION (3) o"00
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KllOIF��
NAYM 130 WAMOCTM Snt "•SMJM4 MAMACHLIUns 01970
M.97L7SS-9S9S*FAx 976740-984
HOMEOWNER LICENSE EXEMPTION
Please Print
Date 7 I U
Job Location /S 14" k I aJ 0 .. S-1 lC t rµ tit C'C 9 Z C
Home Owner Address i -� ! c., 4-k c c.1 _ w1 l4 eo�71 S 7C
Home O9vaet Telephone — S`i< S
Present Mailing Address 'r -ec -, �. '4— C4
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.
DEFINITION 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 "homeowner"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
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
..v.".r•1 6tt• {lya`I L
>�,,.. t�Gtr.,etcv::owSatrsT•ieee�r.>uvev n.sns.:44
Construction Debris Dtsposst Affidavit
(required for all danolidlaa and removatiau world)
in xcordanee with the sixth edition oohs State Building Cods.7SO CAIR-soctios 111.11
04bris,and the provisions of NGL a 406 S A
Building Permit A ._ . _ is issued with the condition that the debris resulting hors
this work shall be disposed of in a property licensed wants dispo d. facility as defined by%4GL e
td1. S15"
The debris will be transported by:
Vz, C 2
--- tn�tw,,r tuut•�
fhedebris will be disposed of in :
(114aw of ixdAty)
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EmtvrS
PUBLIC PROPERTY
DEPARTMENT
XMWENAW DRAWL"
N►wa I-V Wwutwlcw S'nssr•sMrK.MAUM3Ks9„s0197o
APPLICATION FOR THE REPAIR. RF.NOYATION_ CONAIRLCEieN_
D&MOLTTION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTX4G
STRUCTURE OR BUILDING .
1.o srrE INFoww►noN -
Location Name: 14.rsh (e7,,J it-cc &Ad ft (S
---- - Property Add-- J` -
Sti (tom � ✓�- U/`r Z o
Properly Is looted In a;Conservation Ares Y Hh t ft Okuld
ZA OWNERSHIP INFORMATION
2.1 Owner of Land S co f f M vwh, ti
Name: S cr,/-f
Address: Is
Telephone: - 7(f - U S`f S
3.0 COMPLETE THIS SECTION FOR WORK IN>7tlSllelO BUILDING$ ONLY
Addition Existing 3
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
Construction of renovation 06 ')
of existing building New
add Description of Proposed Work: ���k • �cw� �y�' S
Cj M v r!(y f2(/UG✓� Qt yt�� (2r.` T�hv` �;1
61
--- - - ---Mail Permit to: _ �f M LI V w I s l s h l s.i S5 4- l i,,✓f lS 7a _-
What is tM Curent use of the Wlding?
4 wi,
Materialerisi a tiu0ding?
l If dwelling.how manywwW?—S—f-1ZI
Will Ow euMV Cordbrm to t.aw7 Asbestos? YI -
Arohitsd's Name
Address and Phone l
medwesName
Address and Phone
Construak+ Supervisors license a HIC Registration 0
Estimated Cost of Projed: o o ° Peme Fee CakxdsdOn
Permit Fee i — Estimated Cod X$71111000 Residential
Estimated Cost X$411:1000 Commsr3101-
M Additional $5.00 is added as an
Administrable dWgI (�
Make sure that all Saida are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Buildbv Permit to build to tine above stated
specilicatkm Signed under penalty of perjury X
Date 21 O
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