23 LEMON ST - BUILDING INSPECTION (3) a
Ct
AtfQS�dlIIST�E fIL{-C idfll APPROVED BY T44E
t .fJA�CT(?A ,PRLDRTpp`PERMIT.B,EING GRANTED
l� CITY OF SALEM
UNU� ✓
.
No. / •� "� b�`r Date23
( 3
i"
Ward
N6 Zoning District
Is Property Located In Location of 1 ,p
the Historic District? Yes_No_ Building 3 '�CVV16
Is Property Located In
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Ro2f--F1eroQ.f, Install Siding, Construct Deck, Shed, Pool,
epair/Replac , Other.
PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name
Address & Phone 123 1125�IionJ (`I38 ) Sys -07.-)3
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone t ( )
What Is the purpose of building? 4L/,ee ,hsLjk/eL- 4-4, LAs
Material of building? &601C+ If a dwelling, for how many families? /
Will building conform to law? Asbestos?
Estimated cost City License # State License #
Home Improvement
Lic. /
Sighature of Ap Jicant
7, SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION/ OF WORK TO BE DONE /QO/ac, e< gn �f�e„ C. ,A K/�"', e� hR /,ouot r /Cvr�erzr�
2 ba5e s n /4,rell�
PLIf- iiz l 641r
MAIL PERMIT TO: iZ3 '44�9wd tJ
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?{qs^,N fdOR y,,.f 1w5kd„§.. fan 3W,k+� b n gbu; P vri""o
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I
Of 1 rSf 'Y.in.k�'nLD,`A ✓M1. .,yrY�JS '4J�X;„rF' t.��:,} "AeP�.eflrA .w✓ �..4�r�ffa v. S>ES,�,
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CITY OF SA1EM
BUII..DING DEPARTMENT
HOivEowNER LICENSE EXEtv1 nON
Pleast Prim
DATE b/lo -C' 3 Ii
JOB LOCATION
. HOMEOwr1ER �3 ��� 5��2 �� �•¢ ass�v
ADDRESS
HOMEOWNER 9 iS 0?0 3:
TELEPHONE
PRESENT MAILING ADDRESS- 4-^�
The cuma exemption of"homwwners"was extended to include owmtroccupitd dwcllpp of TWO
Units or less and to allow such homeowners to engage an individual Sur hive who does not posses a
license,provided that the owner act as supervisor.
DEF24MON OF HOMEOWNER:
Person(s)who owns a parcel of land on which he/sht resides or intends to reside6 on which there is,of is
intended to be,a one to two family dwelling,attached or detached smXI'mes accessory to such use tmdlar
farm structures.A person who const-um mart than one home in a two-year period stall not be considend
a homeowma. Such"homeowner sh-a'subndt to tht Building Olirdal,tm s form ac=pmbk m tote
Building Official,that he/sht be Tcsponsiblt to all such work performed tmda tht building pamk
The undersigned"hommwmcr assumes responsibility for compliance witbtht State Building Code amd
other appb able goes by-laws,Tula and regulations.
The tmdasigned"homeowner" certifies that he/she undcmands the City of Salem Building Department.
minimum inspection proccdums and requirements and that Nshe will comply with said rvoc as and
Tcquircmcum
HOMEOWNER'S SIGNATURE
APPROVAL OF B=ING INSPECTOR
See other side for stau code
L
e r•
HOMEOWNER'S EXEMPTION
The code states that "any homeowner performing work for tivhieh a building permit is requned shall be
exempt from the prmisiow of this section (Section 1A9.1.1-Ucensing'Of Construction Supervisors);
Provided tbat is a homeowner engages a person(s)for hire to do.stcb work,that such bomeowner shall act
as supwtsm."
Many homeowners who use this exemption are Gmwan that they an asswnutg the tnponsibMtks cif
,.ism (see Appc Ddix Q,Ruin and Regulations for Licensing COnstruction Superviwrs,SeCom
.2.14 This lack of awareness often resilts in serious problems,particularly when the horneovrrwbhu
uriliccrued persom. In this case your Board cannot proceed against the unlieeased person as it would with
licensed SupCnisor. TIC bOmeM'D.tT saiag as supervisor 17 uhimstdy rssponpible.
Wn'biliti commurdties as
omeowncr i fu] aware of hi/her es, req�. pt+rt
To cnstae that the h s lY respo ntanY
understands the ibilides eta
permit a liotion,that the homeowner certify that he/she �Po�
of the pp ,
)x
supervisor. You may care to amend and adopt such a formlkxnificatioat for use in)'Off�4•
I .
CI`TY�OF ZALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
s 120 WASHINGTON STREET, 3RD FLOOR
a SALEM, MA 01 970
TEL. (978)745-9595 EXT. 380
FAX (978) 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: K /rZ
Location of Facili
&AetL. /6-rio-o3
S& ature of Pkrrnit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
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.