67 LORING AVE - BUILDING INSPECTION (3) Y y
The Commonwealth of Massachusetts
Board of Building Regulations and Standards W-
This
y J Massachusetts State Building Cude. 780 C'MR. 7'"edilion
/ ai
Building Permit Application To Construct. Repair. Renovate Or Demolish aOne-or Two-Fumdv Dwelling Section For Official Use Only
Building Permit Nu r: Date Applied: Y1/U t I
ti
Signature: ( - ( 0
Hus'edinlFcommissiorurd Inspector of Buildings Oale
SECTION I:SITE INFORMATION
I.1 Property Address: 1.2 Assessors Map& Parcel Numbers
L la Is this an acce ted street? es no Map Number Parcel Number
I Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) 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:
Public❑ Private O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record
CY�o_ ,Cci �7 (Arw� pv�
XName 'nl) _ Address fur Service:
c(w-s - 9-7g ys—��
Si Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) Cl I Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
45
fLCG� /0 y
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: ODlelal Use Only
Labor and Materials
I. Building s I. Building Permit Fee:s Indicate how fee is determined:
=Electrical s ❑Standard City?own Application Fee
O Total Project Cost'(Item 6).x multiplier x
s 2. Other Fees: s
al (IIVAC) s List:
al (Fire s(MiOTotal AH Fees: s
Check No. Check Amount: Cash Amount:
tect Cost: s ram, 0 C7 Cl Paid in Full 0 Outstanding Balance Due:
v
SECTION!: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name ul'CSI.--I lulder I.isi CSL rype(see below)
r Description
Address U Unrestricted u to 35.000 Cu.Ft.
R Restricted Ia2 FamilyDwelling
Signature M M� (MI '
RC I Residential Routing Covering
1"e1eph011e WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
FA-JJdmw
egistered Home Improvement Contractor(HIC)
ompany Name or I IIC Registrant Name Registration Number
Expiration Date
re 'fclephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. Ill. 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 ..........0 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. -
sistrudureorowner Date
SECTION 7b: OWNERS 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 Nome
Si *lure of nera uthoriad Agent Dale
Si ned u rthegainsandpenalties of 'u
NOTES:
1. Owner who obtains a building permit to do his/her own work,or an owner who hire an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will rW have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Constroction Supervisor Licensing(CSL)can be found in 7110 CMR Regulations 110.116 and 110,R3, respectively.
When substantial work is planned,provide the information below:
Total tlaors area ISq. Ft.) (including garage, finished basement/attics.decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
kNumber of bathrooms Number of half1baths
f heating system Number of decks/porches
f cooling system Enclosed Open
otal Project.IS,
Footage"may be substituted for"Total Project Coss"
• i
CITY OF SM-E.N1
PUBLIC PROPERTY
DEPARTMENT
`L"1Oe i ao�rmuncrrou sneer�sura�Nwsuoastrn oN'0
r9L 9'a•745-95" • FAX 97e•740-9W
HOMEOWNER LICLNSE EXE..M"ION
Please Print
Dam 7 i�
Job Location
Home Owner Address C-7 er !�rw m.cw �- e
Home Own Telephone 9I e) 0.� yz-7 f-
Present Mailing Address l) Co+,.v c w e
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 who does not possess a license.provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) who owns a parcel of land on which he/she reside@ 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 fort 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 understands the City of Salem
Building Department minimum i rocedures and requirements and that he/she
will comply with said procedures require ents.
HOMEOWNERS SIGNATL `
APPROVAL OF BUILD G 'SPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
l ' DEPARTMENT
'1'1:1: 'I"i-74i:9i95 I'\s: 7'8.74J.954t,
Construction Debris Disposal Affidavit
(MILlired for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CIv1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(uame ul facility)
(address ul 1'acilily)
a
signature of permit applicant
date ---
tL I"i.arl i!"C