85 MARLBOROUGH RD - BUILDING INSPECTION What is ft Current use of the Building?
Material of BuMft? If dwelling.how many unit ?
Will the Bui&V Confbrm to Law? AsbestaT —
AmhamasNan>•
Address and Phone
MedwWs Name
Address and Phone
Construction Supervisors Liewee f► NIC Registration S
Estimated Cost of Projectct L � �Ov Pena Fee Cala+latlon
Permit Fee S Estimated Cast X S7f1111000 Residential
Es wmw Cat X:11/S1000 Commen:14 -..._ .
An AddMwW$5.00 is added w an
Administrative dwge.
Make an that all fields are property and iegiby written to avoid doWA In processing.
The undersigned does hereby apply for a Building PemrA to build to the above stated
specillcatk m. Signed under penalty of WWI
Date -l__
Z � N
O
U
< � w
x y 4
---- — - �-- yr— a-- --
GrrTUFSs�Eb
PUBLIC PROPERTY
DEPARTINMNT
N Ewa 130 WAAuN=W 9rteer•
&MAr< srrnotWo
APPLICATION FOR TLEZ REPAIR.RENOVATIAN C STRU TION .
DEMOLITION. OR CHANGE OF USE OR 900MANCI SR IMG
IMMMORIUMMG
1.0 SITE INFORMATION
Location Name: . 2 t 9uMft
_. PM"
F6- lyl�6(-
�3��co�G t�
Property is 10 r In a:Conservation Ares YIN Hlstorla Dhtrld YIN
2.0 OWNERSHIP INFORMATION
Zt Owner of Land 7g
Name: c
Address:
Telephone: )i--79!3- q07-3
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTINrNew
Addition
Renovation Number of Stories
Change in Use
Demolition
Approximate year of Area per floor(sf)
construction or renovation
of existing building
Md Description of Proposed Work:
�Nrb v� �r- �,e�6���✓G-Ge e�9-s� S'�De ��v�E
Mail Permit to:
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KI NDIEBLEY DRISI:OLL
MAYOR I2D wASHINGCON SIRELr•SALEaI,MnssAaluserrs 01970
TE:978-74S-9595 0 FAx:978-7a0-98"
HOMEOWNER LICENSE EXEMPTION
Please Print
Date 611/,07
Job Location
Home Owner Address
Home Owner Telephone
Present Mailing Address Eog oV 6-
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 j
"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 SIGNATURE
APPROVAL OF BUILDING INSPECTOR 2 g
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12C 1t'.\91tVQi ON S i-REET •SALV%1.M.\1i.\C,R IL1T5 J 191:
TF.1.:978.745.9595 0 E+x:978.740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CNIR section 111.5
Debris, and the provisions of ViGL c 40, S 54;
Building Permit #di _ .___ is issued with the condition that the debris resulting from
this work shall be sposed of in-a properly licensed waste disposal facility as defined by V1GL c
111.S 150A.
The debris will be transported by:
GOON f}C — 9:1e1. /GfI�)
(name of hauler)
The debris will be disposed of in
K,19 Ls/7Jff_Il9r,&_Y(E _
Wa ne�of facility)
-- a :atu,a of p,:nr,it appacaat --
9