15 LARCHMONT RD - BUILDING INSPECTION (003) r► CITY OF &U.EM
PUBLIC PROPERTY
DEPARTMENT
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NAVOR 130 WMNb .-TOM STRM 6 SMAK MAWAGMSErIS 01970
71EL 97a-745-9S"*FAx.976740-9646
HOMEOWNER LICENSE EXEIMMON
Please Print
Date 0
Job Location %CJ'
Home Owner Address
Home Owner Telephone 9 7 a-- 7 y 4/ -
Present Mailing Address 1.S' A-rdl,m0
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 fora acceptable to the Building
Official, that heJshe 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
12C W.\94%A::0N5.'xEF.T •SAti N. WAI&W;x A:1'lb%91.
Ts):9M743-9595 •F.%r:978.74CG9846
Construction Debris Disposal affidavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 730 CNIR section 111.3
Debris, and the provisions of M. GL c 40, S 54;
Building Permit # _ . __ is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by.MGL c
I11. S 150A.
The debris will be transported by:
— (name of haxliU L/
I'lie debris will be disposed of in
('14me of Iadlrty)
—_�z?
:.ddres. of C�ciLly)
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PUBLIC PROPERTY
DEPARTMEAIT
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Vwroe 130 WAUUNc.WW th%=•
�N�suaa:se'rrs 01970
1tl 97e-74&gS"0 PAZ 97L740.9W
(FOR THE REPAIR. RENOYATION CONSTRUCTION
DEMOLITION,OR CE ANGE OF USE OR OCCUPwN Y,FOR ANY EXISTING
STRUCTM OR B nDING
1.0 SITE INFORMATION
Location Name: awwkv
Property Address:---
Property Is bated in a:Conservation Arsa YIN HkWft DWMd YIN _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 4_5'&� Al
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXlt3IlNG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing ,
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
&iet Description of Proposed /Work:
------ ---Mail Permit to:
i
What is the Current use of the Building?
Material of Building? c*lo a 2� If dwelling,how many units? Z
will the Building Conform to Law? _—
Asbestos? --
Archited's Name
Address and Plane ( 1
Mechanic's Name
Address and Phone
Constr cation Supervisors license S HIC Registration
Estimated Cost of Projed S °° o PermM Fee Calculation
Permit Fee S y 0 Estimated Cost X$71$1000 Residential
Estimated Cost X i41/i1000 CanmerCiak---- ---- --
+%7 `l An Additional$5.00 is added as an
AdminWmttve 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 build to the above stated
specftatbns. Signed under penalty of perJury
Date i
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