26 MARLBOROUGH RD - BUILDING INSPECTION EITY OF
PUBLIC PROPERTY
DEPART NIENT
MAYOR 120 W.ASWNGrON-SMEEr
,
/ a EL-978-745-959S�F x 97&740 8" 01970
7_ � t
APPLICATION FOR THE REPAIR- RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
6
STRUCTLF OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
t Property Address: G�', lY1�r�c ✓3p QONG N l��
Sf4-6TOI Ail
Property Is boated in a; Conservation Area Y/N Historic District Y/N
I 2.0 OWNERSHIP INFORMATION
2.1 Owner of Land "
Name: ' 14;q 1- .9M1e7-0N
Address: yG 01AW46096ut-'Y- -
SAL�1-r+� My3-
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
E Renovation Number of Stories Renovated
Change in Use New
{ Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New.
Bde De
scription escrription of((Proposed Work:
A,4 J t'F,o— a'{—
u � �1'�Z r'ear c� •�1.._ l[�� �u( Ir�s, �.,c(~...l �.S
Mail Permit to: - -
What is the Current use of the Building? A ILI
If dwelling.how many units?-- —
Material of Building? wdo
Asbestos? /U
will the Building Conform to Law? y�
Architect's Name
Address and Phone
Mechanids Name
Address and Phone
Construction Supervi
sors License# HIC Registration#�---
Estimated Cost of Projed$ 2S0 Pe Fee Calculation
Permit Fee S --- Estimated Coostst XS7151000 Residential
Estimated Cost X$11/S1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penally of penury
Date
W � __
r
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERIEY DRISCOLL
MAYOR 120 WASHINGTON STREET♦SALEM,MASSACHUSETTS 01970
TELL 978-745-9595 • FAX:978-740-9846
HOMEOWNER LICENSE EXEMPTION
Please Print
Date l0
Job Location 2G /G rAt>+ o L4 4 0
Home Owner Address 2-A
Home Owner Telephone 9 -' S - :7 q S -$ -? Z
Present Mailing Address z6 414 16D"4✓1 9d
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 and requirements.
HOMEOWNERS SIGNA"I`U�F_ -
APPROVAL OF BUILDING INSPECTOR
See other side for state code
1
Homeowner's Exemption
The Code states that: "Any Homeowner performing work for which a Building Permit is
required shall be exempt from the provisions of this section (Section 109.1 —Licensing of
Construction Supervisors);provided that a Homeowner engages a person(s) for hire to do
such work, and the Homeowner shall act as Supervisor."
Many Homeowners who use this exemption are unaware that they are assuming the
responsibilities of a Supervisor(see Appendix Q, Rules and Regulations for Licensing of
Construction Supervisors, Section 2.15). This lack of awareness often results in serious
problems,particularly when the Homeowner hires unlicensed persons. In this case your
Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The Homeowner acting as Supervisor is ultimately responsible.
To ensure that the Homeowner is fully aware of his/her responsibilities, many
communities require, as part of the Permit Application, that the Homeowner certify that
he/she understands the Responsibilities of a Supervisor. On the last page of this issue is a
form currently used by several towns. You may care to amend and adopt such a
form/certification for use in your community.
CITY OF SALEm
PUBLIC PROPERTY
DEPARTMENT
waaw��av nasoata
yAras 130WASUMM MSnFst•sAL"MASSACHLSSMOMM
1$:MIAS-ft"•FAm M746.9Mia
Construction Debris Disposal Affidavit
(required for all demolition and renovation wont)
la accordance with the sixth edition of the State Building Code,M CMR section 111.5
ochds.and des provisions of MC L.s 40,9 A
Building Permit M is issued with tits condition that the debris mmWng flom
this wort shall be disposed of in a properly&.eased waste disposal &cility as defined by MC3L a
111.S 130A.
The debris will be transported by:
Jam/Az, �i I v D
� u AA1rC
(same a(hwish
The debris will be disposed of in
VVor 'h, 5 Lot
✓
(aama of fruity)
(addma of hedity)
C-- LAI,�
sisoaaue of pemur applicant
due
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