210 JEFFERSON AVE - BUILDING INSPECTION x d
-Pk* S*1"S"E f No OVED BY T+IE
1NSPF.CxLiR i 31QA D' .P E1NG GRANTED W
f N
CITY OF SALEM
N3\ fT, �1 \ Date
16 Properly Located in Location of
to Hlatodo DWdct? Yas_No
la Properly Located In
Cn Coneervatlgn Area? Yw_No //
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Root, Reroof, Install Siding, Construct Shed, Pool,
Repair/Replace, Othep
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCUBII*IG
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name a in i_e 4e t� to n c
Address & Phone 2, I0 IV L4 7 v y 7 s
Architect's Name
Address & Phone L )
Mechanics Name
Address & Phone
What Is the purpose q b AdhV?
M"W of bWk1W WD d d tl a dmWft,for how many IamYio?
wm lx kbv conform to law? i//P, S Ad"os? )Vd
tEsMusted cost 0 0 0- Qd CUy ucerao Y N p' stab licanea N
ful II ;.
Hoes hwro.mnt
IA1 Signature a pplicant �.''�I 'i
SIGNED UNDER THE PmorMN
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
/ �� - filq 'lIP i11
f
vN ��w,l1f MAIL PERMIT T0:
I
V
No.
APPLICATION FOR
/ PERMIT TO
l Dn 57�rk.. 71��9 dPL l�-
LOCATION
PERMIT GRANTED
y/ /0!1 Zo
APP OVfD
INSPECTOR O BUILD . S
soma" g
3 I^-
i
CITY OF SALEM
B=ING DEPARTMENT
IiCh E.OWNER LICENSE EMOMON
PIC=Prat
DATE �/ -�l
JOBLOCATION l o -_�e-Ape/ S6 n �
ijolowrm( I D J r, Ile i S 6.6
ADDRESS 7
HOMEOti1T7f�t I / Y Y 7 �
TELEPHONE
The crarcu c:cmmpttion of-bomewwnas"was c-Nunded to bxludc owccT-9=. fed dwcM'V 4TWO
Units cc kss and to allow such bomcownas to cnpp an irrdi 16W for bite who dm toot proses•
litimse,prw4dcd tbm the trwocr act as superviwc.
DEriNmON OF HOMEOP1AlFJit•
Pcrsou(s)who awns s parul of land on which Wshc resides of iaunds to reside,on wlikh�tt=��
inicnded to be,a one to two family dwclling,a-ached at dctached structwvs scrosM to
farm nvcwm A person who connructs molt than orx hams in two-ycw puiod s>rall hotbe caasidaed
a bomeow nar. Such`h0mtpw7r-f &half submit to the Bulding O$rcial.art a form atxtpssbk 1a tart
Building Offrcial,that Wshc be resporasabk to all suds work paforntcd tardcr the builaiirtg pcsadl.
The undenipred"bou=wtrcr"assumes rcPOWnbility for comPlirmoc with the Stan Bn9rl'rng Code tttd
other appbcabk I=by-laws,nits and tcgublitmt
Tbc undcnigncd'hov=wncr" mrtMts that hdshc imdaT ands the City of SWern Building Depat•onmt
rnWmwn ins on proccdmu and rcgrmcm Tess and that Wx will comply with said Vmm ma and
rW 1
HOMEOWNER'S OW 'S SIGNATURE
APPROVAL OF BU➢.DING INSPECTOR
Sex otter s do for strac code
HOMEOWNER'S EXEMPTION
The code:tins that;`arry homeowner pesForming work fm which a but7di tg permit is regtitred abaD 1lx
exempt from the provisions orthis section (Section 11 11-Lictmog of Coostruetioo SuptrAwri);
Provided that is a homco ttKT engagts a person (s)for hart to do.such wank,that aitt b Lomeow=dhall ad
as supervi�
May honwownen who use this exemption arc unaware that they We assmning the?upoasr ds• r
srrverviwr (set Appeodia Q,Rules and Regulations for l cxvslog Coostruetlon Supet•rison,Seck smm
2.15} This lack of awareness often results in serious problems.particolariy when the Loraeositw Lfn�
v%
unlicensed persoat In this case yew Board earuwt proceed against the mtlieeased person as it truld wig .
licensed Supenistn. Tpt bewwwoer acing as suptrvisor in uWmateiy r srmsf ft
To ctuurc that the homeovrncr is fully aware of hirer responsibilities,rrrarsy eammtudties regiare;as petal .
of the permit applic26M that the homeowner ccrufy that he/she tmderarards the responsibilities Celt
supenisor. You may cart to amasd and adopt such a form/ccrtifiertim for tsse in your eoirtmusdq,