111 LORING AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
�- Board of Building Regulations and Standards CrrY OF
l 1 Massachusetts State Building Code, 730 C,VIR SALE��
1 Revised Mar 2011
\� Building Permit application To Construct, Repair, Renovate Or Demolish
One-or Two-Family fhvelling
This Section,For OfFicial Usa Only.
Building Permit Number: D't ApQhed>,
� • U-cuz � Z -
BwldingOfficial(Print Name) Signature _J Date
SECTION 1:SITE INFORIVIATION l
1.1 P perty Address: 1.2 Assessors Map& Par I Numbers
L l a Is this an accepted street?yes_ no Map Number \_P,arcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(it)
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 Informatioa: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
S19CTION2:, PROPERTY,oWNERSIIiYL
2.1 O ertofRecord:
� �",
Nameyrint) City,Stata,,ZIP
,/ (A) Loct(v51-,
No.and Street— Telep one Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owne Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ J,96mberofUnits_ Other ❑ Specify:
Bn Description of Proposed Work':
l &ss-( W �y (OnL. Ulf l_ Pac T_1A)
rcut- EEO
SECTION 4: ESTINIATED CONSTRUCTION C STS
Estimated Costs:
Item Labor and Official Use Only. .
ivlateriais
I. Building ; 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S Q Standard..City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing i ? Other Fees: S
1. ,Mechanical (IIVAQ S List:_ j
i. \Iaeh:mic.tl (Piro
1iip c=ion) __ $ l'utal All Fees:
I'n t.tl I'rnjce[ ('nit S
Check No (.heck Antountt C,uh \uwuntt
n
' { i ❑ P ud in cull ❑ Out,t:utdia" I) it urea
SECTION 5: CONs'rRUCI'ION SERVICES
5.1 Construction Supervisor License (CSL)
Number ---_ 8spiruiun Date
License
I lnme ufCSL Ifolder List CSL rype(see below)
Type Description
No. and Street
IJ Unrestricted Duildin s up to 3i,0170 w. lt.
R Restricted U2 Family Dwellin
City/town,State, LIP VI I%Wonr
RC Ruutin Coverin
WS \Vindow and Siding
JD
Solid Fuel Burning Appliances
Insulation
Isle hun Email ad
g dress Demolition
5.2 Registered Hone Improvement Contractor(I1IC)
C Registration Number Expiration Dale
I IIC Company Name or IiIC Registrant Name
No.and Street Email address
City/To n, 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 72: 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) Dnte
SECTION 7h: OWNERh OR AUTHORIZED AGENT DECLARATION
By enteri my name below, I hereby attest under the pains and penalties of perjury that all of the information
can ed i plication ' t e and accurate to the best of my knowledge and understandin .
:turo Date
\utlwritcd:\vest's Name(Electronic SIgt t )
i I'filtt V\Y ller'i Jf,
NOTES:
I. ;\n owner who obtains a building permit to do hisiher own work,or an owner who hires nn unregistered contractor
(nut registered in the H)ute Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty timd under M.G.L. c. I42A. Other important information on the I IC Program can be found at
www m:u:,eovroca Information on the Construction Supervisor License can be found at ttww.lu:tss.,:u� ,
2. When substantial work is ph ned,provide the information below:
I'otal tloor area(sl. tt.) (including garage, finished hasementhttics, decks or porch)
i O;; living area(";q. ft.) _-- — f fabitabla room count ----
Number of tircpluccs _ Number of bedrooms —_
----------
Number of bathrooms Number of Imit-I aths _.
-—------------
hvpe of hotting ;y;lcnl Number of deck;/purdl N _ - ------
peot,Cool ing, ;vacnt _-. f:ueloscd tpcn
1. I'mil I'1 .t o y he ,Ib;unit-:.I t,,r I tjI I'rnj�d l l,t -- - -
CITY OF SM-EM
PUBLIC PROPERTY
DEPARTMENT
V�uWlfr�fOLLYL
Vwva 130 W uowr-WW hoar•1LLLL NUW Aaw SKM On sro
ML 9-8445.11" •v,.s 93.7+61)a+e
HOMEOWNER LICLNSL EXE1.MrrlOV
Please 1Mit
Due 2` i3
,obLoeaeio. I 11 �.e�r�►�g 1 .9e� e-A-f*L� r�
Home Owner Address 411 1--0 1 W cj
Home Owner Telephone
Present Mailing Address hi I 1 nt,i yoe, 77m
The cunwo exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or teas and to allow Such homeowners to engage m individual for
hire who doe not possess a Heense�provided that the owner acts as supervlaar.
DEFINMON OP HOP"OWNER
Perwo(s) sobs owns a pwA of land on which Wshe resides or intends to reside6 on
which there is6 or is intended to be4 a one or two family dwelling, attached or detached
structures accessory to such use and/or rum structum A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"honseownee shall submit to the Building Official,on a form acceptable to the Building
Official, that hehhe be responsible for all such wort performed under the Building
Permit
The undersiSnW "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable bylaws and rejuladon&
The undenigined "homeowner"cerd Iles char he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
Will comply with said procedures and requir rnEL /
HOMEOWNERS S(GNATLRE
\PPROVAL OF SUILONG 0iSPEC7'OR
See other side far state coda
I
CITY OF S�1LZNfj Nass:ICHUSETi'S
BULONGDEP.IRTM NT
120 WASHLYGTON "STREET, 3 FLOOR
T EL (978) 745-9595
<!J[BE1tLEY DRISCOII F•tie(978) 740-9345
NUY011 Dtou"ST.PIEMS
DIRECTOR OF Pl:SUC PR0PERTYI8LMDLYG CONNISSIONER
Construction Debris Disposal At'8davit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section l 11.5
Debris, and the provisions of Ib1GL c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal racility as defined by IVIGL c
111, S 150A.
The debris will be transported by:
(nan1C Ut'IIQUICf)
Tile (lebris will be disposed of in
O
(name offacility)
(adJress of taalhly)
signature ut permit applicant
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