414 LAFAYETTE ST - BPA 07-473 REPAIRS PUBLIC PROPERTY
DEPARTMENT
KINSFa1.EY DRLWA .L
MAYOR
120 Wnstunwnntl5rREEr•u,�W.ASs.ACH st7'M01970
TIL 978-745-9595 9 FAX 978.740.9846 (�
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION "
Location Name: — Building:
Property Address:
Property is located in a;Conservation Area Y/N Historic DleWd Y/N /V
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ✓� `� Losc f S k
Address:
I cl tcc-Fckyc f-►-c s f- .
Telephone: 97W-- 7 L-j Ll - 0-S -z
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTruG BUILDINGS ONLY
Addition Existing 3
Renovation Number of Stories Renovated
Change in Used New --
Demolition a Existing—
Approximate
year of i` ' Area per floor(SO Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
l�ck '� J The SrJ"!S of Tarc jS?64cVi'c-ti vo, li
74a.F ;S hr1j accn 4 +e, T is 3cic cC- Y-j
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What is the current use of the Building? hou 3 i n Material of Building? C c> ----
if dwelling. how many units?T—
< < a
Will the Building Conform to Law? S _ Asbestos?
Archited's Name
Address and Phone
i
Mechanic's Name `}}
Address and Phone HIC Registration# t
Construction Supervisors License#
Estimated Cost of Pro' S o Q Permit Fee Calculation
Permit Fee$ Estimated Cost X$?/$1000 Residential
Estimated Cost X$11/$1Coo Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building;;e
uild to the above stated
specifications. Signed under penalty of perjury
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
xl%MER F.Y DRISCOLL
MAYOR 120 WASHINGTON STREET•$ATEM,MAscncHuserrs 01970
71Ei 978-745-9595• FAx:978-740-98"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date ( I/20/AAA
Job Location L� ( � lct (�j C fi-f-E S
Home Owner Address L-( l Li l Ct ��.++e S 1
Home Owner Telephone V )�— 7 U Lt —0 3 340
Present Mailing Address L41Li 14 fG.�c t+F S F
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 INSPEC OR
See other side for state code
Homeowner's Exempdon
The Code states that. ,Any Homeowner performing work for which a Building Permit is
required shall be exempt from the provisions of this section(Section 109.1 —Licensing of
Construction Supervisors);provided that a Homeowner engages a person(s) for hire to do
such work, and the Homeowner shall act as Supervisor." ;
Many Homeowners who use this exemption are unaware that they are assuming the
responsibilities of a Supervisor(see Appendix Q, Rules and Regulations for Licensing of
Constriction Supervisors, Section 2.15). This lack of awareness often results in serious
problems,particularly when the Homeowner hires unlicensed persons. In this case your
Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The Homeowner acting as Supervisor is ultimately responsible.
To ensure that the Homeowner is fully aware of his/her responsibilities,many
communities require, as part of the Permit Application, that the Homeowner certify that
he/she understands the Responsibilities of a Supervisor. On the last page of this issue is a
form currently used by several towns. You may care to amend and adopt such a
form/certification for use in your community.
CrrY of SALE,m
' PUBLIC PROPERTY
DEPARTMENT
wsarnan cauaosr.
H.roa t3ovv�swswisss sessar•sKaa �snso»»
Consimcdos Debris Dispaat Affidavit
(required fay all danolidos sod movsdos vacs).
Is acmdsnea with the sbrdt edW=ddw Same Building Coda.7SO CMI satiao 111.5
Debris,sod dw provisions of MCM a 406 S Sit
Build ns Permit M is isaaed wid the 000didost tbat the deb k roubles doom
thb wart d aq be disposed of in a psopely lieeosM waata disposd Ateility as Mined by MCL o
1u.s11tu
no debris will be bumport ed by:
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104nc� �cn,JGM n ko sofs
(samealbdJol
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The debris will be disposed of in:
lvo '-r� Si ac CC.tY+i`n
(anima of f&MY)
(awn"of&C tiry)
msaamra of penal app rot i
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