34 LORING AVE - BUILDING INSPECTION r
J 7 --- I'fie C'onunonweallh of Mussachusclts
�Y y; '.A Ilnhrd of Building Regulations and Standards (TIN OF
Mail achusetts State Building Code, 7SO C NIR �.\L1;\I
Building Permit Application 'fo C'unstnteL Repair, Renovate Or Demolish a
One-or Tne)4'a miff Ghveffin,V
This Section For Official Use Only
j
Building Permit Number. _ Date Ap lied: _
Building 011lclal(print Marc) Signature Data
SECTION 1:SITE IN
ATION
1.1 Property Address: 1.2 Assessurs Hsp S Parcel Numbers
1.la Is this an mce to street?'-es no flap Nuather Parcel Number
1.3 Zoning Infortnatlon: 1.4 Property Dimensions:
Foiling District I'roposcd U4, Lot Area(sq Ill Frontage(Ill
1., Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wate upply:IM.G.I.c.40.134) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
14fblic' tcs
private O Zone: _ Outside Cheheckkif iHood Zone? Munieipd�n site Jispusul s)+tem O
�
SECTION2. PROPERTY OWNERSHIP'
2,1 ern of Race d: � �7
�1�eXal�r �r ��r�fiti ��v`�1�stnlf //'/G( CJ/9D7
Mutw(Print) City.State,tip
/I Parson s ;,rL21&
Nu.and Street reltphune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building Owner-Occupied CI I Repairs(s) C3 1 Alteratlon(s) di Addition ❑
Demolition O Accessory Bldg.p Number of Units_ I Other O Spcciry:
Brief Description of Proposed %Vor � Eap
0 02 F Low f StG�ir� r �11 leg- LG le
SECTION J: ESTIMATED CONSTRUCTION COSTS
hero Estimated Costs: Ofllclul Use Only
(Labor mid M merials)
1. Building &V I. Building Permit Fee: S Indicate how lee is determined:
'. likarical SMf�'O�
O Standard CityiToln Application Fee
Total Projeet Cost (Item 6)x multiplier
}. 1'lumhiog S +, Other Fees: S_ -
4, Mcolalwal III%' W) SList:
\Icch,mic.d t Poe '— •---- -------- - -.. .__ . .
`u fechanic Sturd \II Fees: S
n Potal Project CuNt: S ('hccA No. _...__('heck :\nnnun: _ __.._. l'.ieh .\nunuu:
10 P lid in Full ❑Outstanding Ilal.mce Out::
SEC HON s: ( ONti rRI1( n0N SFHVI('F:S
5.1 ('onstructiun Supen isur License(('SI.)
✓ I wvow Nanthar •. 'q Fspirlwo D;ne
J_ em s. )1.._.. .
N;une of C51 I IulJer I m CSI. I)pe hee heluls 1._ v
'I Pe Desaripliun
No. and Slreel
I l�nrcitricmJ U Ito lJin s li to i4,IIIlU cu. It
�J� r r 1
���;UGPf�-{'y' /!',(�_�i f q.3� R li¢+IricteJ IK_I.uml Dttcllu
--- _ \ \lason
i'ren "I"Ic.Lll • I
L7- I. .
µ(' µtsoin Cocain
N:S R'indoo, and Siding
.— SF .Solid Fuel Homing Appliances
'12LY-7y-Vv4 I huululiun
rN
hone 14nail uddras D Demolition
Registered llume Improvement Contractor(HIC) t1 19DILJ
7Qu1 �it^ IIIC'I(Cgistrmiun Num r Ihpinllitm Data
Company N uc nr I IIC'Itc isuwn Nunw
W1 S d Email address
• ���� �sf�� nip .o193d 9�t��Y79117a6
City/Town,State ZIP tale hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 26C(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 AMdavit Attached? Yes ..........a No.........
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR`APPLIES FOR BUILDING PERNIIT
Z
I,as Owner of the subject property,hereby authorize 7
V es //P�,
to apt on/mybehalf,in all matters relative to work authorized b his building permit application.
-� Al r°A R-,
Print wicr's Name(Eicctrunic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this applicati n is true and accurate to the best of my knowledge and understanding.
Ihim Oener's or Authurired Aycm's Name Date
NOTES?
I. •\n Owner sshu obtains a building permit to do his her own work,or an owner who hires in unregistered contractor
(nut registered in the Hume Improvement Cuntractur i HICI Program).will nu have access to the arbitration
program or guarulty fund under M.G.L.c. 142.4.Other impurianl information on the HIC Program can be found at
Itu.s ore••. n • . 1 Information on the Construction Supervisor License Can be found as It 11 s m•n �; s Ip�
2. \\'hen substantial cork is planned,provide the inl'unnatiun below:
rota) (lour area(sy, 11.1 _ __.._I incluJing garage, finished bascntant attics.Jerks or porch)
Grois lining area I sy. It H;tbitabla rounl count _ ..
\unlherol'lirvplaces .... _... . . Numberol'hcdroonls .. . .
�unlhcrol'halhr.wnls _ Numbcrul'11a11'haths
I)pe it 11e.nmg i)item) Xumhcr ofdccks. porches
I'
h)pC o1 h4ohng i\U•'I❑ I'IteIUKd ( ell
1. "Ioial Proico ';quive Fklotewc III;$) he:uh,litulcd f1or..1'nl,d I'mjc.9 Co,t-
CITY OF S:1LE.%[, N WSACH I:S ETTS
e�
BCILa NG DEP.IRT}(ENNT
120 WASHLNGTON STREET, 3w FLOUR
F.uc(978) 7 9).9844
vj%tpEERt FY DRISCOLL
NLAYO2 T tio+LU ST.PIERAZ
DIRECrCROF PUBLIC PROPERTY/SUrMING CO>12-IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contruc torVElectric(ansitPlumbers
A i tlleant Information i ase Print Legibly
.Nainc lBmitu+rUr mr:niumlmlividual): -
Address: %✓l Vt°�S ' 1 f,
City1Sr3tcjzip: lT/( , ,0f74? `AA
Are you an employer!Check the appropriate box: 'rype of project(required):
1.0 lain a employer with a. 0 I am a general contractor and 1 6. ❑Now construction
employees(full and/or part-lime).• have hired the sub-comnetor rt�
1.XI airs a sole proprietor or partner. listed on the attached shcce. t 1, M Remodeling
ship and have no employees These subcontractors hove V. ❑Demolition
working liar me in any capacity. workers'comp,insurance. 9, 0 Building addition
(Nis workers'camp.insurance 5. 0 We are a carparati•Sn and its
required.) afOcer have exercised their
10.0 Electrical repairs or additions
).❑ 1 am a homeowner doing all work right of exemption per MOC I I.0 Plumbing repairs or additions
myself.[No workers'sump, c. 152,91(4),and we have no 12.C]Roof repair
insurance required.)t employees.[No workers' IS.C]Other
Gump. insurance requireq
•.vuy appfl,ua cut Jllcaea box I I mast Jiro all ,,,tha action below showing hair waken'compenudun policy inAi moaon.
r I I,v ,:uwnwv wha,whaiil this rnldavil Indluaing iheV m doing all Iwre and then hire uuaide oanletctan moal Johmil a new a7ldavil indicting we&
:1Lmnctun that chwit this hux mual anoahsd on Iddiuunal.htwl Jhowing the owns or the db4Untmtere and III&wnrkae•whip.policy InPotmadon.
/mn an anp/uyer rhutJx pruvEJlnX rvorkers'cumpnrradun lnaurunee�or my ernpluyrrx, Below is Ju policy and fob silo
in�ormwlnn.
In JOnnice Company Vmne•. __......_
Policy 4 or Self-inu. Lie.4: Expirulioas Data:
Job Silo Address: CuylState/2:ip:
A itacb a cnpy oilhe workers'compenSatlOs policy declaration page(Showing the polity numbor and expiration data).
F iiluru to w4ure euverage as required under Suction 21A of VIOL c. 152 can lead to the imposition of criminal penalties of a
tine up to 11,500.01)and/or one-year impri.mnmcnl,ax wall as civil penalties in the form of STOP WORK ORDER and a line
of up to S2)0 M a day Jgainat Ilia Vlolatar. Ile advl.ted that a copy of this Tlatcment may bu forwarded to ilia Onica of
1�1vc�li g.ltiunt ofilic DIA furinaurancc coverage veriticuliun.
/du hereby verb y locum rho painr mid penaldes of perjury thus the in/urowNat pro vidad ubuvr i.r true surd t.•arrrrR
`42
I�r�•,t �d'= Sf7� -�Y7��
Ol iciul rue only. Oa aol weitr in Mir area,m he rmupl�IaJ by lily ur town nj/Trio!
C;ry of l'u,rn; PermitA.lccnte i
h,uiou Atillwrily (circla onc):
I. Huardnl Ileahh '. Iluildln, Delclrlulent I. f ilyi own Clerk i, Electrical I'I,pector i, Phunhint luepeetor
G. Other
t'nnl nit I'e r,n n: 11hons d:._
C;tTl' OF S.1t. Nfs NL1SS.ICHC'SEZ'I'S
O3 LLDLNG DEp.im(L\T
,10 120 7-WINGTON STxW, Jw FLoat
rM J978) 741_9599
KISrHFRf Av DVXOU P,Vt(973) 70.9&g
. .tiUY01< MOSW ST.pillls
MUCT011 OP PLaut aRoveaTY/ecMDa4G co�aussrovt a
Construction Debr1S, DISPO Sal At
ftdavlt
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CUR section I I I.J
Building
and the provisions of MOL o 40, S 34;
Building permit,y
his work shall be is issued with the condition that the debris resulting from
t is
of I, S 1 JOA. in a properly licensed waste disposal racility as defined by,�la. e
I I
The debris will be transported by;
(name of pourer
The debris will be disposed of in
roam.or raciufy) '�`—
s�
fiddreiiorr�, t,iy)
9 / urpermit�ppri�ant