30 LORING AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
CITY OF
M
uk
�IassacBoard of Building Regulations and Standards
hnSe State Building Code, 730 CNIR S ttS Revisedd Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Divelling
This Section For Official Use Only
Building Permit Number D'f , p 'ed;
Building OF cial(Print Name) _ _Sign re Date
SECTION 1: SITE INFORNIATION '>
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Al, N, ei.
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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.G1 c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private❑ Check ifyes❑ Municipal$( On site disposal system ❑
SECTION 2:"PROPERTY'O WNERSHIPI
2.1 nert of'Ycord:n
/7/' x� l-t. rQ'&' /5�/,6yFsr.
Name(Print City,State,Z
No. and Street ( 'Telephone ne Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) 0, Addition ❑
Demolition q Accessory Bldg, ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=: i Ylf tca
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
[tem Estimated Costs: . Official Use Only,
Labor and Materials
1. Building S ` 6 oe 1. Budding Permit Fee $ Indicate how fee is determined:
Electrical $ G Co ❑ Standard City/Town Application Fee2. .
❑•rotal Project Cost',(ltem 6)x multiplier. x
3. Plumbing S 2. Other Fees: S
4, Jdechanical (HV,\C) S List:
3. Mechanical (Fire $
Su : ression) Total All Fees: .S
�� Check No. Check Amount: _Cash Amount:
6 "Total I'rojcct Cost: S 13 dd� , ❑ Paid in Full 0 Outstanding Balance Dua:__— __
r r
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
GJ /0S365 _ License Number Expiration Date
Name of CSL 1-folder
List CSL Type(see below)
VGA(!kM e ' �ll G7 Type Description
No. and treet - '
� 7 �/r� R Unrestricted B Famidinly
s u el in , cu. ft.)
� �- R Restricted 13c2 Famil Dwellin
City/Town, State, ZIP NI blasonr
RC Roofing Covering
G WS Window and Siding
SF Solid Fuel Burning Appliances
92ya�� Insulation
"1'ele hone Ertidil/address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
gx//ivL x t HIC Registration Number Expiration Date
11IC Company e or I CC Registrant Name
�,-�� �
No. and Street _ matl address
7 ��11/C'dSz' Sf /c7 �b� 71�i
City/ own, State, ZIP 61 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
1, as Owner of the subject property,hereby authorize dCcV!✓l L5 A&/�
to act on my behalf, in all matters relative to work authorized 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 ac rate to the best of my knowledge and understanding.
Print O ncr's or Authorized,- gent's N e(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(nut 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 litC Program can be found at
osvw.ne ss.< ov oca Information on the Construction Supervisor License can be found at www.mass.soV.(I
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) _(including garage, finished basementfattics, decks or porch)
Gross living area (sq. 11 _ Habitable room count
Number of fireplaces_ ---- Number of bedrooms --
NUtt[ber of bathroums _ Number of halt/baths
Type of heating system __-- _ Number of decks/ porches
I'ypeuFcoolin" "'tem ------,— Hnclosed-- -_---_--Open _—_--
i. `'I'u[aI Ptoject Square Footage" may be substituted for"['Ural Project Cos["
i' CITY OF &U Em, NL-1SS:1CHliSETTs
w BUILDING DEPARTM&NT
130 WASHIINGTON STREET, 3aa FLOOR
T FL (978)745-9595
FA.'c(978) 740-9846
CV�[BFRT RY DRISCOLL
MAYOR TTIOMAS ST.PIF3AS
DIRECTOR OF PUBLIC PROPERTY/91 mnizzNG CO\L\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibty
Name(Omiiwsyorgtnixatiorulndividual): r )G\\/Jhl YS Z21L-l�4
Address: 7 ,q Lz/rVS e Sf
City/State/Zip: /bl, ,`>>936 Phone hl:
Are you an employer?Check the appropriate boss Type of project(required):
1.❑ 1 am a cmploycr with 4, 0 I am a general contractor and 1 6. ❑New construction
employees(roll and/or part-time).* have hind the subcontractor
2. 1 am a sole proprietor or partner. listed on the attached.sheet-t 7. ❑Remodeling
ship and have no employees These subcontractor have V. 0 Demolition
working for me in any capacity. worker'camp. Insurance. 9. 0 Building addition
(No workers'comp,insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repair or additions
myself.(No workcra'cutup. c. 152, $1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.LA'o workers'
comp.insurnce required.) 13.❑Other
-My applicant thm chceka box el muat also fill uul the uclioa bclaw showing thaw warkam'mmpanmlun policy ineurmallom
r I h.evowm"who submit this afllolavit indleming they am doing ell work and then him outside contractors most submit a now amdavil indicating wetly
!Gmuxlam that check this box most attached:n additional short showing the nwna of the sob comeactem and shots workers'comp,polity infonomtan,
l um an employer that is provfdlnA worker'rotrtpensodan insurance for my einpluyeex Below/a the pollry artd Jab she
information.
Insurance Company Name:
Policy 4 or Self•ins. Lie. d: Expiration Date:
Job Site Address: City/Starr zip:
Angels a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failuns to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as wall as civil penalties in(he form Ufa STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. lie advised that a copy of this statement may be furwardod to the Office of
Investigadons ul'tho DIA fur insurance coverage writicution. -
l do hereby certify under pules mtd penuldes ufperJury that the btfurntallon provided above is true and correct
.
5i I )atu: /__� — /-3
P o ,� — _7
I (Vicial use only. Oa not turile in thGt arrest to be completed by city of town of efert
Cityar'ruwn: __-_- Permit/I.lcensek
Issuing Aullierily(circle one): I -
I. Board of health 2.Buitdinu Depurnnent .1.Cilyfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Cunlact Person: Phone K•
CITY OF SALEM. NL�SSACHUSETFS
1 BUII.DL\G DEPARTUE,�IT
130 VVASHLNGTON STREET, 3" FLOOR
TEL (978) 745-9595
FAx(978) 744D-9346
KI\t13ERLEY DRISCOLL
&LWOR THo.%w ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUUM NG CON12MISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section t 11.5
Debris, and the provisions of NIGL c 40, 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 disposal facility as defined by MGL c
111, S I50A.
The debris will be transported by:
�Ir/L G
(nant of hauler)
The debris will be disposed of in
(name of facility)
/
(address of facility
si5 ature of permit applicant
1- o?y-/3
date
dcbris.il�•Lw
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30 LORING AVENUE 611-13
Gis#: 14023" COMMONWEALTH OF MASSACHUSETTS
Map: 32
Block. — CITY OF SALEM
Lot. 0082-802
Category: REPAIR/REPLACE
Permit# 611-13 BUILDING PERMIT
Project#n„ JS-2013-001981
Est. Cost $13,000.00
Fee Charged: $96.00
Balance Due: $ 00. " PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License: Expires:
Use Group: - - - JAYMES ALLEN Home Improvement Contractor- 105308
Zoning: I Owner: BARMEN ALEXANDER
Units Gained: - Applicant: JAYMES ALLEN
IUntts Lost:-' I''"" '"AT. 30 LORING AVENUE
IDig Safe#
ISSUED ON. 07-Feb-2013 AMENDED ON: EXPIRES ON: 07-Aug-2013
TO PERFORM THE FOLLOWING WORK:
CHANGE ROOF PITCH IN EXISTING ROOM TO CREATE MORE HEADROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chinmcy:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House 9 Smoke:
Treasury:
Water: Alarm:
ASS¢S$nr
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING RFC-2013-002158 07-Feb-13 CASH $96.00
IQcoTMS0 2013 Des Lauriers Municipal Solutions,Inc.