4 LOONEY AVE - BUILDING INSPECTION �V
The Commonwealth of Massachusetts Town of
Board of Budding Regulations and Standards
Massachusetts State Budding Code, 7g0 CMR, T"edition Building Dept
Budding Permit Application To Construct. Repair. Renovate Or Demolish a
One. or Tiro-Familt•Dwelling
This Sectigii For Official Use Only
Building Pernn Number Date Applied: b/^
Y\ Signature: v
V Bolding ommtsvonerl In t ildtngs
Date
$EMibiti I: SITE INFORMATION
I.1 Property Addre$a: 1.2 Assessors Map k Parcel Numbers
1.I a Is this an acce to sireel?yes no Map Number Parcel Number
1.3 Zoning Information: L! Property Dimensions:
Zoning District Proposed Use Lot Area(sq 0) Frontage(R)
1.3 Building Setbacks(R)
Front Yard Side Yards Rest Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system
O
Public O Private O Cheek if esO p y
SECTION2: PROPERTY OWNERSHIP'
2.1 Ow er'of It cord: ,
sine(Print) Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(ebeek all that apply)
New Construction O Existing Building 0 Owner-Occupied O 1 Repairs(s) O 1 Alteration(s) O 1 Addition O
Demolition O Accessory Bldg.O Number of Units_ I Other O Specify:
Brief Description of ProposedWork':
�®d>✓\
XVV
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building f I. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical f ❑Total Project Cost'(Item 6)x multiplier x
J Plumbing f 2. Other Feea: f
4. Mechanical (HVAC) S List:_
s Mechanicat (Fire S Total All Fees. f
Su resston
or0 Check No. _Check A aunt: Cash Amount:_
6 Total Project Cost: S 2 Paid .n Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supers isor(CSL) go ��
'S L,crme Vumbw Es ratio ale
N�tit 'SL- jyWer List cm
Type 1,ce brluw)�_
T Description
A sf ` U Unrestricted u to 35,000 Cu. Ft.
l R Restricted IAt2 Family Dwelhn
nature M Masonry Only
RC Reiidential Roofin Covering
rlephone ///��, ��` /// w'S Residential Window and Siding
/J ��-
y 7 �' Y SF Residential Solid Fuel BurningAppliance Installation
! / D I Residential Demolition
5.2 Rftredl H tote Improvem mt Contractor TIC)
HIC omp Nam or HI pstiam Regis cation Number
Expiration Date
gi Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. e. 152.1 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance a uilding permit.
Signed Affidavit Attached? Yes.......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
( as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I as Owner or Authorized Agent hereby declare
that the statementsAna information on th foregoing application are true and accurate, to the best of my knowledge and
behalf,
b5
ame �
Sitiffioneol'Ov,gWor ihbrized Agent I Date
St aid under th&bains and penalties of r
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor I HIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L. c. 141A. Other important information on the H►C Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110A5. respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementtattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Type of heating system Number of decks/porches
Typeof cooling syctem Enclo.ed Open
1 Total Project Square Footage"may he uh,lifuled for-'Total Pro)cci Cost"
. r6 CITY OF S.-1I_EM, ANSSACHUSETTS
BL'BDLNIG DEP.IRTNMST
l'_0 WASHLNIGTON STREET, )sa FLOOR
TEL (978) 745-959S
FAX(978) 740-9&M
Ki-(BERLEY DRiSC011.
MAYORTHODtu ST.P[ERM
DIRECTOR OF PLBLIC PROPERTY/gL'ILDNG CONDaSSIONER
Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricianslPlumbers
t licant Information Please Print Legibly
Nagle (Busimt organtraiomindsvtdu:d):
Address: V6§- 2
City/Statc/Zip:s;! O�eW4 AV Phone #: ) 7 01
Are you mployer?Chuck the appropriate boa: Type of project(rtequlred):
I. I am a employer with _/ 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time)."' have hired the sub-conuaomrs
2.0 1 am a sole proprietor or partner- listed on the attached shceL : 7. ❑ Remodeling
,hip and have no employees These sub-contractors have I. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. Building addition
(No workers' comp, insurance 5. ❑ We are a corporation and its
requited.)
officers have exercised their 10.0 Electrical repairs or additions
).❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[Na workers'comp. c. 152,41(4),and we have no 12.0 Roof repairs
insurance required.) t employees. INo workers. l3.❑Other
comp. insurance required.]
-Any applicart the choclu glad el muN alwr fill out the section Indent sheeting their WW km'camper nliM policy infurmLlat.
'I Lvtxuwtswe who suh nN this anidevk indicting they are doing all work and then him amide cantrecsws toot suhmb a now allldevit indiCrsing suelL
:C.tntreelnm ohm ,hrek this lom mud anwhod an additiatd Joan showing an mne of DIN Ju4eonlleetare end their wurkam'cunt'.pulicy infer woo
/am an employer that Is providing workers'compensation lnsaronce far my employeex Below is the policy otrd fok slfe
information.
Insurance Company
Policy #or Self-ins. Lie.p: �o'O %� j� J�� Expiration Date: e7
Job Site Address: r? Z1e City/StatriZip: 4Q4 7l�
,\ttacle a copy of elm worken'.compen tloa policy declaration page(showing Rho policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250,00 a day against the violator. Ile advised that a copy,of this statement may be forwarded to the Office of
Invcartgatiuu ul the DIA For insurance coverage verification.
l do hereby certify under the pains and pen fes of per/a that the information provided above is true tnd caned
`I"t 't Dat : �
Phon A:
Official we only. Do nor write in this area, to be completed by city or town official
City or Tuwn•. y _. PermiV1.IcenseN___
i
hsuin \ulhoril (circle one):
I. Ituard of Ileallh 2. Ruildlnu Department J. cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
G.mtact Person: _ --, -- Phone p:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
110W.\il ll.\G';7?NyrNECT #S.\I I`\I, %1.Ni.\1111
frt' )78.743: ;95 ♦ 1'\3:978-740.9446
Construction Debris Disposal Affidavit
(required fur 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 It... _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
i 11, S 150A.
The debris will be transported by:
1
Inamc of \a} er)
I'hc debris will be disposed of in
✓// e ✓
Qt:une ut (aahty)��
laddress ut taclluy) _
Signal of permit applicant /
date