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Jd$AEdL�B r9fWA D AFING GRANTED CITY OF SALEM
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BUILDING PERMIT APPLICATION FOR: 1
Permit to:
(Circle whichem apply) eroof, Install Siding. Construct_Deck, Shed, Pool,
RepaldRep . Other.'
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROONSWO
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to fhe folWminp
specifications:
Owner's Name 45ro,04 R 6 rn R Lo K; vJ
Addresa & Phan 15 ja u 2 - (- s-r 117& 1 1tf5-e. 3 C,j
Architect's Name
Address & Phone ( 1
Mechanics Name
Address & Phone
I . .
What 1s in p apoaa of M~
,Not,
mde"of I~ N a dwaNMq,for how many hm6a4
WN bm&v=dorm l01aw7 AOEagoo4
ENMmW1 v CRY Um"rr N A 8Wa Llmm a� `� v
v s� �Lie. i
'-Signature of Applicant
SIGN40 UNDER THE 1,111110ft
OF PERJURY
DESCRIPTION OF WORK TO BE DONE '
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C A i� 'D r vE SILL
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MAIL PERMIT TO• '
;1Y
No.
APPLICATION FOR
,n PERMIT TO
g` of �•i�— Resk,i� �ti/lc� - .
LOCATION
PERMIT GRANTED
APPA6VFo
INSPECTOR OF BUILDINGS
3 •
CITY OF SAUX
B=ING DEPARTMENT
HOMEOWNER LICENSE MMOMN
pkasc PM
DATE
JOB LOCATIO!'1
HOMEOWIgR �(S Lca u ke L S T
ADDRESS
HOMEOWNflt 1 i"rn A/if R 0 r7i IC3 jro(A J
TM FFHONE
PRESENT MAnV..G ADDRESS 1 L t-�a u 2 r L S
The etarerd Gxempd of"homeowners"was r-%urded w mcludc o+rocrocwpled dRef60ta dTWO
lln3tS W less and 10 allow SUCH homeowners 10 cnlage am indnYldU31l0e hue ph0 doer Aol poastys� .
liccnse,.pmvidtd d m the ow"Y ad as WPtrAw-
mracTlON OF HOMEOWM'
Pcrson(s)wbo owns a pm=i of land on which Wsbc raida m intends to ttside,om whkhh*lk Or b
intended w be,a one to two fam•Iy dwelling,swdied or detached saucnaes atxesaM to
farm structt m A paean who constructs mmz than om hmne in a rwo-ycat period sba11%a be considered
s homcoww. Such`homcolkw-f shall subrtdt to the Btuldinl Official.on a loan sez:pcabk m des
Building OMeitd,that hcJshe be rtsponsibk to all such work pafonacd mAu the buDding p=
.Thc unda-lpsed"bomeowna"ass==rmpon�bnk for Complimncc with the Stau BUB&g Code m d
othu appHcabic lots by-laws,toles and TegubliomL
The tmdasipicd'homcowna"mrd5a that htishc undcrram&the City of Salem Bw mg Dcp vma.
minimmo its on pmc cdwcs and regttincntcnts and that Mahe will caruply with said v=cdum wA
*w
HOME011TlFR'S SIGNATURE c
17
APPROVAL OF BUDDING INSPECTORL2
Sec otba s do for state code
I
HOMEON"ER'S EXEMPTION
The code--utcs that.• `any homeowner performing work for which a buDdmg permit is reytitred Ad be
c:umpt front the provision of ibis section (Section 10P.117-Uecosiog of Construction Superrisor I.
Providcd,tbat is a homevvmcr engages a person (s)for hue to do.such worlr,that Fitch bomeowaer shaD am
as
MAM bormowners wbo use this exempkion arc unaware that they arc asstua'vrg the rzsponibmau a[a
stiperviwr (sec Appcodla Q,Ruks sod Rcgolatioor for vatesiog Coostruedon Superv{wrs,Sec*u
2.iS} TLia lack of awareness often nnilu in serious problems,particularly whrn tht herneosrrier bbU
unlicensed pctsom In this tau your Board cannot proc=d against the miliecmed prnou u U world wi&
licensed Suprnisor. The bomeenver&ding as supervisor b uldtmste�rssEonstbN,
To ensure that the homeowner is fully aware of hinwr nupm-ftilides,many eommmddes require;as peal
of the pernit sppl'tadvA that the homeowner ecrufy that hdahe understands the responsibilida eta
supcnism. You may care to amend and adopt such a fwmlccnif=atim for wt in your Ca
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL (978)745-9595 EXT. 360
FAX (976) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL 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 III, S 150A.
The debris will be disposed of at: _A),66'7-A -5/�✓i= (St RIt
Location of Facility
v Signature of Permit Applicant bate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
ZF_6t4) 11-ktl col �,l..ca � ti
Name of Permit Applicant
Firm Name,if any
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, S150A, and the building permits or licenses are to
indicate the location of the facility.
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