67 LORING AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY
Board ol'Building Regulations and Standards
Massachusetts State Building Code, 780 C'MR, 7i°edition OF SALEM
t RevisedJunrarry
Building Permit Application To Construct, Repair, Renovate Or Demolish a
�r One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit No er: Date Applied: YZ
Signature:
ABU,, maommissioned Inspector of Buildings Date
SECTION I: SITE INFORMATION
1.1 Propeyty Address: 1.2 Assessors Map& Parcel Numbers
CCcyr,,cv�,nye
L l a 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 it) Frontage(11)
1.5 Building Setbacks(R)
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: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Q--
Name -nnt) — w Address for Sery
.CQ 9 Off
�Signalure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building O Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ AdditioJO
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specity:
Brief Description of Proposed Work'-: —74 S2. g
trG
SECTION 4: 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
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
3. Mechanical (Fire S
Suppression) Total All Fees: E
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S (j, 0
0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSI.-1 holder List CSL"fype(see below)
r Description
Address U Unrestricted(up to 33.000 Cu.Ft.
R Restricted IB2 Family Dwelling
Signature M Masonry Only
RC Residential Routing Covering
felephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Siµnalure Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.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 of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........O
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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Dale
(Sianed under the pains and Penalties of 'u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R5, respectively.
?. When substantial work is planned,provide the information below:
Total floors 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"
CITY OF SM-E.M
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXE.M"10N
Pies" "I
Date 7 /O
Job Location (0
Home Owner Address r. t '
Home Owner Telephone q-M 4Z 11 9
Present Mailing Address (r-)Z a-ve--
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a licensor provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Pason(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
Officiak 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 understands the City of Salem
Building Department minimum i non edures and requirements and that he/she
will comply with said procedurI requirem ts.
HOMEOWNERS SIGNATL
APPROVAL OF BUILDIN SPECTOR
See other side for state code
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