22 LORING AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts CI"I'1'O OF
Board of Building Regulations and Standards CITY
3?,iy Massachusetts State Building Code, 780 CMR Revised.11ar 201!
LbW
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tmyu-Fuumily Dmvellhkif
This Section For OtTifoal Use Only
Building Permit Number: D to Applied: � 1
11
Building Offim I(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Nlap& Pare umbers
92, Lor-ING &L sclera Yh0. 01'70
Mu Number Parcel Number
1.I a Is this an accepted street?yes_ no
P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arca(sq It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal s stem [IPublic❑ Private❑ Check iryes❑ P p 5
SECTION 2: PROPERTY OWNERSHIP'
2.1, pwner q Record:
j -lie Ilar ,njel5 �m ma Q1170
Name(Print) Ciq,State,'l.IP*
c�a Lr��lnc l�ue lw� L�I� 460-1o71a1 llt ,llc �to� r�aho�,cavt
No.andNo.amd 5 Telephone mil Addre s
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied Er Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other E(Specify: fCN00o k-N 9
Brief Description of Proposed Work2 10,2
II a I ko 6" °f
tlet}r r 1 rut f
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
i. Plumbing S 2. Other Fees: S h/
q. Mechanical (IIVAC) S List:
5. mechanical (Fire S Total All Fees: S
Suppression)
Check No. _Check Amount: ---Cash An10m11t:----
6. Total Project Cost: S — 13 Paid in Full ❑Outstanding Balance Due:
r '
SF.C"IlON.5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
__ _ License Nwnbcr 1[ytimtion Uare
N:unc ol'C'SI. I IulJcr
List C'SI.7)'pc(See helow) —
Nu. and Slrcet - Type Description
U Ihirestrieted(Iuildin•s u' to 35.000 Co. 11.)
City/loco.State,ZIV - R Restricted I&..hmnil .... n
M Mason
RC Roolin,C'overm
W'S Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Tcic hone Fntail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
No.and Street
Email address
Cit /Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. ¢ 25C(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 of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7e: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understandin
11Q E�wr.)Jds a //
I'nn Owners or.\ahorized Agent's Name(Llectronic Signature) Date
NOTES:
7(not
er who obtains a building permit to do hisiher own work•or an owner who hires an unregistered contractor
tered in the Hume Improvement Contractor(HIC) Program),will nor have access to the arbitration
or guaranty fund under:\I.G.L. c. 1q'_A.Other important information on the HIC Program can be found at
�s 84S"c;l Informal ion on the Construction Supervisor License can be found at;,w,a.nctss.gu,)Ips
stmnial work is planned, provide the information below:
a(sq. R.) _(including garage, finished basement'attics,decks or porch)
Gross living area(sq. 11.)—_ Habitable room count
Number u(fireplaces Numberofbedrooms --- --- -- --
Nuntherofbathrooms _ --------------
NumbcrufhalE'bathi
1' pe of heating system
-----_--____--- Number of decks, porches
-I)pcufcoulint: syslem
-----__-----_.-._-- Enclosed _ Opcn
7 "lolal Project Square Footage-may be substituted for"rota) Project Cost"
CITY OF S.UxDof
PUBLIC PROPERTY
DEPART1tENT
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HOMEOWNER LICENSE EXEMPTION
�' Pfease FMet
► ►
Job Location ?a L.ort ry g d er-ut- 5ral orn , nig Bl 9 7U
Home Owner Address 2'1 Lor'N . I m i m Q (51 g w��
HomeO, Y'YY
w,vne,r_?elepne ho !o I _t 7- lor7-ln7 to I
lR Present g Address a2 L- -,NC AA- S� Io m rY),n. 6/C7
The current exemption of"Homeowner"was extended to include owner-occupied
dwellings of taro Unit@ or leas and to allow such homeowner to engage an individual for
him who,does not poaaeae a licensee provided that the owner acts as supervisor.
DEFWMON OF H011t1EOWNER
Persons) 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 dweWng, attached or detached
structures accessory to such use and/or farm stntctures. 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 001164 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 bylaws 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 itequi ents.
HOMEOWNERS SIGNATURE l l
APPROVAL OF BUILDING bNS CTOR
See other side for state code
CITY OF SM.&M, AASSACHUSETTS
BCILDLNG DEPARTIENT
110 W.1iHmGTON STRM, Joe FLOOR
T-EL (978) 745-9595
KIJBEJtLBY DRJSCOLL
F.kx(978) 740.9846
MAYOR TNo.%Lu ST.PMA"
DIRECTOR OF PLBLlC pROPEATY/BL'Q.DLVG CO\pltSSfOV Ell
Construction Debris Disposal AtEdavit
(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 1* is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S I50A.
The debris will be transported by: v�
th rna c c.),-Vf 9. of hauler)
The debris will be disposed of in :
CC (name of facility)
..Js�✓arnoSCo� KGaC� Sc 1An yhFl
i
(Iddress of racihty)
�iynamre olpermrt applicant
2LO€
Jate