210 LORING AVE - BUILDING INSPECTION \� The Commonwealth of Massachusetts CITY OF
EIVEO Board of Building Regulations and Standards
SALEM
NAL SERVICE:.
Massachusetts State building Code, 780 CMR Revised.lkrr 1011
Ao}J Bu�'Id' met Application To Construct Repair, Renovate Or Demolish n
�\ IS DEC 2 3 H W One-of Two-Family Dwelling
This Section For.OfTcial Use On :
Building Permit Number. Date:App
Building Ot7iciel(Print Name). : Signature.•;'. Dote
SECTION 1:SITE INFORMAT1UN`
L1 Proer Addr /� 1.2 Assessors P Ma &Parcel Numbers
P. iY ;yt) Ipaij,
1.In Is this an aces tedstreet?y�no &too Number Parcell Number
I1.3 Zoning Information: 1.4 Property Dimensions:
zoningDistrict ,: .. Proposed Use I Lo(Area(sq il) Frontage(R). . . .
1.5 Building Setbacks(R)
..
Front Yard. Rear Yard$IJe Yatda.
. .RequiroJ Provided Required- . .Provided Requb . Provided
1.6 Writer Supply:(N.G.6 c.40,§54) 1.7 Flood Zone Informations' t.8 Sewage Disposal System:
Fairlie D Privets O.
Zone: _ Outside flood Zone1 ' a MunieiO On site disposal system 13
--:: - Check if k aO
SEC'CION 2: .PROPE�t1 Y:OWNER$RIPt
2.1 Owner'of Rwrd:
(liter—
ttnc(Print) Cnyr stiste,ZIP'Y""` �-
No.and Street Td� '7 Email Addnm . ..
SECTION.J.DESCRIPTION OP PROPOSED WORK;(cheek all tbat apply)`
New Construction O &fisting Building O Owner-Occupied O 1 itepairs(s) 01 Altemtion(s) O 1 Addition O
Demolition O Accessary Bldg-O Number of Units Other O specify:
Brief Description of Proposed%VOW.*
14aU 4'n
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllcial Use Qnly
Labor and Materials
I.Building $ 1. Building Permit Fee:5 Intiteme how fee is determined:
O Standard Citylfown Application Fee
2.Electrical $ p Total Project Cost'(item 6)x multiplier x
J.Plumbing S 2?Qther Fees: S
4.blcchanical (HVAC) S List:
5.Alechanic:J (Fire $ Total All Fees:S
Su ressiun) -
Check No. Check Amount: Cash Amount:
G.Total Project Cast. $ ❑Paid in Full ❑Outstanding Balance Due:
11(011 , `Y) Clk " "Zro zy 5vs 2ts� D�2 Prov .yi� 1 . (Z)Z`l0b
SECTIONS: CONSTRUCTION SERVICES
Zzr
up is r License(CSL)
License um er E-" ali n t6 '11 1 �. t List CSL Type(see below).d
Z �J1P A{moi 1 tq TYPa Description
No.and Street e s
U Unrestricted� Ouildtn u �to 35,000 cu.It.
����.� R Restricted U2 Fwnil Dwellin
Cityfrown,state,zir M Masonry -
RC Roolina Covering
WS Window and Siditut
SF Solid Fuel Burning Appliances
` 1 I Insulation
Cleoone Email address D Demolition
5.2 Registered Ho a mpro Cont ctor(HIC)
HICgtstmflon umber E.pi ?ton ate
ACityrrown.
I C a
Email address
State ZIP Tel hone
SECTION 6;WORKERS'.COMPENSATION INSUWCE AFFIDAVPF ima:L:c.ISL g 2SC(6)}
Workers Compensation insurance affidavit must be complood and submitted with this application. Failure to provide
this affidavit will result in the denial of the Istuango4rthe building permit
Signed Affidavit Attached? Yes......... d No...........O
SECTION Tae OWNER AUTHORIZATION TO BE COMPLETED,W NEN':
OWNEK'S AGENT OR CONTRACTORR APPLIES FORBUILDINC.PERMIT
1,as Owner of the subject property,hereby authorim
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) _ - - Dau
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By enteringpappll*�Vj
low,i hereby attest under the pains and penalties of perjury that all of the information
contained ion' true d accurate to the best of my knowledge and understandin .
Print OwnerjUr, t ri r ge s Name(Electronic Signature) Date
NOTES'
I. An Ownei who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
_(not registered in the Hamelm provement Contractor(HIC)Program),will�have access to the arbitration
progtam or guaranty fbnd under M.G.L.c. Ia2A.Other Important informs ton on he HIC?rogram cante tornd a --
www niass.gov.'oca Information on the Construction Supervisor License can be.found at www.nmss.gov;dns .
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) N .(including garage,finished basementlattics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'fype of heating system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"may be substituted 1'or"Total Project Cost"
_ f
OTY OF SALEA MASSACHUSEM
BLaDmDEPAR7MENT
120 WAS mvwNS7=T,rFLooR
7kL(978)745.9595.
SIIvI6EFAX(978)740-9846
RLEYDRISQ7LL
MAYOR pins ST.PI M
DIRECloxorPuujcPROPEm/BumDmcomm IoNER
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 coo, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
4L Pn,-
(name of hauler)
The debris will be disposed of in:
PILL
(name of facility) '
(address of facility)
Sign ture of applic "
at
,;t
t Mzssac?tuseii>- -�e.par"Me:m o.Put!ic-Safety
Board or Building Regula-Jons and S4andards
Lbn.truetiur,supninflr Spey all -
-tensa: CSSL-099699 ;
e>
ROBERTPOCZOI#UT �_. _
172 WHALERS LANE
Salem MA.019707
cbmm�,icier 02/08/2016
The Commonwealth of massackusetts
Depaytinent of-IndustrialArcietents
Office ofInvest9a ions
600 Washington Street
Boston,Ids 02111
www mars&gov/dia
Worker's, Compensation hmrance Affidavit: Bugders/ContractorsAElecWcians/Plummbers
Applicant Information please Print y.¢ 'blv
Name(susmess/organizatibnanaividual):
Address: by
!
City/5tateop: A)/� > Phone
Are • it an employer:Check the-appropriate boa:
Type of project(required):
1. I am a employer with 4. 0 I am a general contractor and I
employees(full andlorpart time)= have hired the sub-contractors 6- [:1 New consirvction
2.[1 1 am a sole proprietor or partner- listed on the attached sheet t 7. 0 Remodeling
ship and have no employees These sub-contractors have & [] Demolition
working for me m any capacity workers' comp.insurance. 9. Building addition
[No workers'comp.insurance 5- ❑ We are a corporation and its -
I -quired.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGI; 11-0 Plumbing repass or addition,
mysself[Nowoi�'comp. C. 152,§1(4),andwehave no 12.0 fiepairs
e1 ] employees.anc workers' 13 er
Camp-insnance requn:ed_] - Y�ay—
"My applicentthat ehecksbox:I must a$n 811 outthe saoimlaclow showing their wm:Mrs'eompensatioa lie mfotmati - .
Homeowners who submitthis affidavitmdicmmg theyared . a8 p° Y oa g
« doing work and then hire outside manaMorsmust submit a new affidavit indicating such
Contractors that check ibis box must attached an additional sheet showing the name oflbe sub-matatctors and their workers'comp.polieyiaforaiation.
I am an employer that is providing workers'compensation btsurance for my employees- Below isthepoucy and job site
information-
Inmrance CorrpanyNamm
Policy#or Self-ins.Lic. Bxp ration Date: /
Job Site Address: L® �� City/StatP/Zi
p- �c�11Ys rl
attach a copy of the workers'compensation olicp declaration page(showing the policy number and expiration date).
F'Za""M to secure coverage as required under Section 25A of MGL c 152 can lead to the imposition afeaiminal penalties of a
fm'up to$1,500.00 and/or one year nrPrisomtlent as well as civil penalties in the form of a STOP WORK ORDER and a fie
ofup m$250.00 a day againstthe violator. Be advised that a copy ofthis statementmay be forwarded to the Office of
Investigations of the DIA far instuance coverage verification.
Ido hereby certify mepaW andpenaffes ofpedury that the information provided above is and correct
Si tine: Date.
Phone#.- C
Official use only Do not write in this area,to be completed by city or town official
City or Town: Per mitil,dceme#
Issuing Authority(circle one):
1-Board of Health 2.Building Department 3.Cityrrown Clerk 4-Electrical Inspector 5_PIumdling hupector
6.Other
Contact Person:
Phone#:
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