111 LORING AVE - BUILDING INSPECTION (2) i
2.4o 5m
The Commonwealth of Massachusetts
n Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CUR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Builft Pe 't N ber: Da pplie
v E— Z
Building Official(Print Na e) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
_i! i w PiM & yt5
L la 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.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
P£TG'TC c H-1-11 B VJ�IL--IT
Nam] (Print)L0R '1 o M--' a1c3-`R370-2Z7C-6
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 4 Repairs(s) 6 I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': K b-B 'L V F^�^ W�LT'
F[ka Pip—to
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 Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing S 2. Other Fees: $
4.Mechanical (1 VAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
C Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ `2j p 0 Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES.
5.1 Construction Supervisot 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
INS Window and Siding
SF Solid Fuel Burning Appliances
I 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:OWNEW 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�tt.p this ap�licatio is true ayacottrate to best of m know edge and understanding.
{-113tC/�7 � JM1.11�� d f ��✓
�- � 20-73
P ' er* A ed gents 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
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
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"
CITY OF S.U-&Nf
PUBLIC PROPERTY
DEPARTMENT
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sores t b WUMMGrd trust.IM^Vnaow wm et.ro
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HOtL MEOWNER LICLNSB E.XE.tit"101V
Please Mat
Dot. occlsr
Job Loeadm Gll l ,rtPjs 4L e- t
Home Owner Addreae -Sq-.m+r
HomeOwtaetTelephone `tom IR32 T-Tz
Ptssed Mailial Addaw Ilf r`t nw5 � 9
The current exemption of"Hameownae was extended to inchtde owner-occupied
dwellings of two Units or teas and to allow sueh homeownea to engsp an Individual for
him wbo don not poaseae s 8e9084 provided that the owner acts as super *W.
DEFINITION OF HOMEOWMM
Perton(s) *be owns a pueel otland on which Wshe asides or Intends to reside6 on
which thert it; or is Intended to bet,a one or taro &WIN dw@M& attached or detached
rtnrcttues accessory to such use and/or /arm enact wm A parson who consawts more
thm one home in a two year period shall not bi considered a homeowner. Such
"homeownee JW submit to the Building 001ei4 on a form acceptable to the Building
OflIcial, that helshe be responsible for all such work performed under the Building
Permit
The uaderaipcd "homcownce uaumes responsibility for complianee with the State
Building Code and other applicable bylaws and reguladons.
The undersigned "homeowner'cc Mftes that hdshe understands the City of Salem
Buildinll Department minimtun inspection procedures and requirements and that he/she
.viIf comply with said procedures and re5wryments.
HOMEOWNERS SIG VA TUBE V
.APPROVAL OF BU/LD .VG INSPECTOR
See other tide far $fits code
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