242 LAFAYETTE ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
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WAWA 120 wAu„NGW N MEUr•SALE .MAUAd1u5E19s 01970
T EL.978-73S-9S9S 9 Fnx:978-740.984
HOMEOWNER LICENSE EXEMPTION
Please Print
Date Z- //--1 Do /
Job Location .2,,Ye 1,00 -
Home Owner Address
Home Owner Telephone
Present Mailing Address
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;ahorneowner. 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 "homeownee' 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 SIGNATT� � �
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CTTY of SALEM n
PUBLIC PROPRERTY
DEPARTMENT
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To.VW454"s •F.M 9WW"
Construction Debris Dispossf Aftidavit
(required for all demolition and renovation work)
In accordance w ith the sixth edition of the State Building Code, 7S8 CNIR section 111.5
Debris,and the provisions of M. GL c 40.S 54,
Building Permit N _ . _ is issued with the condition that the debris resulting ftm
this work shall be disposed of in a properly licensed waste disposal facility as defined by%4GL c
l l L. S 1.50A.
The debris will be transported by:
G _
—.-- mane of IfSutit)
rite @cbris will be disposed of in
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P P ROPERTY
FDEPARTMENT
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MAroe 130 WALuNGTm bTW=•sA„u4 NAoaaa:seris 01970
APPi,ICATIO 4 FOR THE REPAIR RENOYATI N. CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPMCy= FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
---- -- - -- ply --- - -- -- -------
�t
Property b bested Ina; Area YM IV HIsWft District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land .
Nuns: f-
Address:
Z ✓
Telephone:
&0 COMPLETE THIS SECTION FOR WORK IN El(ISIlMt3 BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brie(Description of Proposed Work:
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--- -- ---Mail Permit to: --- - -
What is the current use of the Building? i B/Jl '�` �'�'i�rir�rl
Material of Building? &Zdd d If dwelling.how many units?
"I the Building Conform to Law? Asbestos? �
Architect's Name
Address and Ptwn 0 ( )
Mochanles Name
Address and Phone
Consir c*M Supervisors LiOrW* HIC Registration N
Estimated Cost Proms Permit Fee Calculation
Permit Fee= Estimated Cost X$7/51000 Residential
Estlmated Cost X i?1/i1000 Ccmmerciat--------_. _
An Additional $5.00 Is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to buildto the above stated
specitioations. Signed under penalty of perjury
Date 9-12-12?a2a 7
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