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CPIY OF SALEM
BU MINGDEPARTMENT
iioNM0WNER LICENSE vM0M0N
Pktue Print
DATE
q -O
)�LOCATIOSI 3 Aa ure l
ADDRESS
HOMM*I Eat
Tn�Plla� .
pKtSEX(MAII.A.G ADDRMS ,y.�
• MW C=cz,Campdon of homeowm i"was t=mded to lrclude ONOCFOCCaY^�d�fflOOp.Of T
Unin Q less and to allow aoth homcowms to=Vp an indmda!l.ia WM wt*does 00"awn a .
license Fpvidcd thn thq owner act v supery w '
D CFHOT`aOP/NEIt
Pcnon(s)who owns a parc ti of land as which Wshe resides or intends to reside,oa•vlde rich h L .
intended w be,a one to two fink dwcllin&snachcd of detad od 50u300 Occ io
aal be at=dared
farm sovcmrcL dPw
A person who constructs awre than tme home in a two-? al oa s lar��a bk to tfts
a hiking w'oer. 5vfi"lwmU be Tt yom-bbk to an so&work pQfoamed WAU the bui *pOWL '.
Building Official.that hclshc be responsr
Mn undersigned"homeowner"asnanrs=pongI ty tot c=S)rm=with the State BuDtffitj Code cud
Diller applicable goes by-laws.rules and tegolanw&
a*A WOK m&nerds the City of Salem Balking Depsm .
The fjrjm m kfi ied *c=n s and that Wsbe WW comply with said prooedma
ad
. rrtinimrao inspction proezd�aes and req .
regair=MM
HOMEOWNER'S SIGNATURE y�' \
APPROVAL OF BUIIDING INSPECTOR 4
Sec other side for start code
HOMEOWNER'S EXEMPTION
The cods states that 'any btmneowm'performing wv*for wWcb a building pertoit Is mpbed Ad be
exempt from the PVo 430115 of this section (Section 70y.L2-1Jaosing of Construcdm Supav{�
Provided that is a bcnmvwn"engages a person(s)for Wm to do.much wort;sbM such bomLowaq slap ga
as
Marq bomcvwnm wbo um this cxcmpdm are Gawarc Ibu they are assmm%g Ilse teapom;bm"are
supervisor(net Appendb Q,Rules and Regulatioae for IJecosiog Coostruc"SUpervbors,Secd.m
.L24 This lack of awwwms cdm tuuhs in acTkm pmbiems,pardt-a"wbm the bomeowm bbu
Uriliecrue cas. pa;oat In this Me yom Board eamnot pn=W against the mtpeeaxd pegoa as it teoold teidl
licensed Supcnisor. The bomeon'cr swing as sops rriwr b UWaostelb resgoospsN,
To cusure that the homeowner h fully aware of M%cr responnmbi8des,marq txmmmddes tagdm.as p■a
of the permii appli®doq that the homemvnet cc7dfy that bclshe Understands Ilse rrapoasibilAIN of e
superAlm- YOU may care to wzmW and adopt suit a formleatYkatim for Ise in yom exuumoolq,
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PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, SRO FLOOR
SALEM,MA 01970
TEL (976)745-9595 EXT.360
FAX (078) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MM c 40,S34,I acknowledge that as a condition
of Building Permit# ,all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c M S 150A.
The debris will be disposed of at: Qz Re Yh a'V a 1
Location of Facility 4
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
LouIS .
j'
Name of Permit Applicant
Firm Name, if any 3
j Address,City&State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.