22 LORING AVE - BUILDING INSPECTION (4) `� Zi��.--T7 t• lJd
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The Commonwealth of Massachusetts FRevisedMar
q� Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A ied:
' Budding Official(Print Name) Signature a x.
1 n SECTION 1:SITE INFORMATION J r—
J 1 1.1 roperty Address:_ , 1.2 Assessors Map&Parcel Numbers P�
r7 ve
t Ma Number Parcel Number
l.la Is this an accepted eet. yes ! no P "
1.3 Zoning Information: 1.4 Property Dimensions: Ul
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required .Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? JI.8
unicipal❑ On site disposal system ❑
Check if yes0
SECTION 2: PROPERTY OWNERSHIP[
2.1 wnerl o Record:
bjo7G>
Name(Print) City,State,ZIP
e ,het
No.and Street Telephone Emai Ad es
SECTION 3,DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
Q r ,� I
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ - ❑Standard-City/Town Application Feb
❑Total Project Costa(item 6)x multiplier x
3.Plumbing $ 2. Other Fees: S
4.Mechanical (HVAC) $ List: -
5.Mechanical (Fire $ ,
Su ression) Total All Fees:$
Cheek No. Check Amount: Cash Amount:
6.Total Project Cost: $ .3�Ip o U ❑Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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 a below,I hereby attest under the pains and penalties of perjury that all of the information
con in din this a ]ication is true and accurate to the best of my knowledge and understanding.
�l
Print Own 's or Authorized Agent's Name(Electronic Signature) Date
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(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
xv v"v.mws."ov,/oca Information on the Construction Supervisor License can be found at www.mass.,ov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,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
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
QTY OF SALEA MASSAmUSEM
a
BUILDING DEPARTMENT
120 WASHINGTONSTREET,31mFLOOR
L(978)745-9595
KAMERLEYDRISODLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF FUBLiCPROFERTY/BUIDM ocMAuSSIONER
Construction Debris Disposa/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 c40, S 54; Building Permit g I I 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:
NA
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
i
Sig a ure of applicant
Date
aCITY OF SALEM, MMSACHUSETTSBUILDINGDEPARTMENT
120 WASFHNGTON STREET,3AD FLOOR
T�L. (978)745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR TrIOMAS STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location a Lori va &e Snbfr, M,4 OIwtJ
Home Owner Address SarvA-Z
Present Mailing Address SO Wn j_
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 that 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
1
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR