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12 MARION RD - BUILDING INSPECTION S V l l 1 Ol S LEry PUBLIC PROPERTY DEPARTNIFNI T AI�MFJLEY DIILtCULL NAYM 120 WnuuN ff W 5%n MEr•SntUk WASSAIX{:5l1'R 01970 14L•978-71i9S99♦FAM 976.740.966 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: IZ c S r�e✓w Property Address-- ----- - — -- - - - -- - -- -- -- - -- -- - -- - _._. I a moo-z -jV Act, Property Is located in a;Conservation Area YM Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: �- Address: �a Mu 2ID 4- Telephone: K S7f- yy- 4?s CZJ SAX - ?s2 - Oo 5 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (so Renovated construction or renovation of existing building New Sdef Description of Proposed Work: I�c$ 1�R� c H1c U III ),z..0 41VIJ eAP4� 0 `F C Dc.J( ----- -_—Mail Permit to: -- I 2 What is the current use of the Building? Material of Building? It dwelling.how many units? Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone Mechanic's Name Address and Phone Construction Supervisors License# HIC Registration# Estimated Cost�of Proj,e.cts� 0 0 Permit Fee Catcuiation Permit Fee$ Estimated Cost X$71$1000 Residential Estimated CostX$11/$1000 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 Perm' uild to the above stated specifications. Signed under penalty of perjury X Date © N O � G F5 a °O C7 ------ /. CITY OF &UEM PUBLIC PROPERTY DEPARTMENT Kf\�IEAIEY DRIS(:OLL MAYOR I20 WASMNGTON SIAEn♦SA `K MASSACHLIS 3 01970 TEL 978-745-9595* FAx:978-7a0-9846 HOMEOWNER LICENSE EXEMPTION Please Print Date l 7 Job Location u ✓ IZI Home Owner Address IA 61�n IZ h� Home Owner Telephone 47g- -7 44- 4 7 S-7 Present Mailing Address I A M o n,j N iZ i> 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 ar�er irements. HOMEOWNERS SIGNATURE e.+ut s�.ri5c wit j- APPROVAL OF BUILDING INSPECTOR 7� See other side for state code �w CITY OF SALEM ;� ) PUBLIC PROPRERTY ZADEPARTMENT _ :;nu:r.anar uniscou. M;1'Ctl' 120 WASHING.-IONSTREET • SALF.M. V1ASSIN(J1 .SL11S 0197C TFt:978-74 9595 • FAx:978-7+G9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit # ____ __ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The eblIris will be transported by: (name of hauler) The debris will be disposed of in (name of facilay) ----- (address of facility) -- - signature of p 6rtuit applicant d to dcbri,afl.anc