112 LORING AVE - BUILDING INSPECTION (5) The Commonwealth of Massachuscus
Board of Building Regulations and Standards
' Massachusetts State Building Code, 780 CMR, 7ib edition Building Permit Application To Construct, Repair, Renovate Or Demolish:It
One-or -Fornily Dwelling
T is Section For Official Use Only
Building Permit Number: 4 4 1 _ to Ap lied:
Signature:
wit
Building Commissions Inspector uil ngs Date
SECfFIAN I:SITE INFORMATION
1.1 Property Address: / 1.2 Assessors Map& Parcel Numbers l-PT Z-
I.la Is this an accepted street?yes ei` no Map Number Parcel Number
1.3 Zoning Information: 1.4 Pro_ pprtgINmensions: //n
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
p 1 s
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage.Disposal System:
Public�tY/ Private❑ p Zone: _ Outside Flood Zone? Municipal site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Zwner of R ord: 1� l
Nu (Print) Address br Service:
�1V) 63 3DS
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) ((�
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ AI[eration(s) ❑ Addition ❑ Q
Demolition ❑ Accessory Bldg. Number of Units Other pecify: ?� d r+]
W
Brie'Description of Proposed Wo kZ: _�
sty✓ />� z tti4 7 2
r d t.�n2.5 Z� r� — .n
SECTION 4: ESTIMATED CONSTRUCTION COSTS Q
Item Estimated Costs: Official Use Only V
(La or a J Materials) `
I. Building S (� I. Building Permit Fee: S Indicate how fee is determined: .
❑Standard City/Town Application Fee
2. Electrical ❑Total Project Cost'(Item 6)x multiplier .x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IiVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:_
6. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
v
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction gSupervisor(CSL) D D Z01
4(vTt�wv� �il Ll�7i� License Number Ivxpirul on U' e
a lie ntc �D L .
✓Jf/l List CSL I)pe(see below) 1
Description Ndr. 00
(1 l Inrcstricted a l0 35,000 Cu. Ft.)
R Restricted 1&2 Family Ihvellin
Si, lure M Mason Only
0/ RC Residential Roofing Co%crin
I'clephone WS Residential Window and Siding
�✓/� / _�J. r7,r� SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registmlion Number
Address
Expiration Date
Signature 'relephune
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
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: OWNEW OR AUTHORIZED AGENT DECLARATION
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
(Signed under the pains and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to Jo 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. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations 110.116 and 110.115, respectively.
2. 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.) Ilabitable 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"maybe substituted for"Total Project Cost"
LOT 78
LOT 79
LOT 80 N23•g5.12"W
125.00'
5.0'
3 L
m PROPOSED
Ir GARAGE
M � fJ wJ�
1� Or (dl G
N 48' 10.0' f�
24.q.
zl.e' LOT 83
LOT 81 LOT 82
AREA=13,408±S.F. DWELLING
rn
zs.l'
19.6' l!
7D.18'
47.82 St6'50'15"E
S26'32 45"E
LORING AVENUE
YH OF MASS
4cy
GAIL rN
o L. ti
c� SMITH No.35043 LOT PLAN OF LAND
�
q A LORING AVENUE
90 cJSTER`` SALEM, MA
Ft
I CERTIFY THAT THE BUILDINGS sALLZAIDSv" PROPERTY OF
HEREON ARE LOCATED ON LORING AVENUE REALTY TRUST
THE GROUND AS SHOWN. SCALE 1" = 30' DECEMBER 13, 2010
1 13 (o _ NORTH SHORE SURVEY CORPORATION
AA
AA REG. PROF. LAND SURVEYOR 47 LINDEN ST., SALEM, MA
#24747
CITY OF SAI.E.NI, .NLvL-kSSACHUSETTS
BUILDLYG DEPARTMENT
120 WASHLNGTON STREET, 3 °FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
KISiBFRr FY DRISCOLL
T
�UYOR �Io.+tAs ST.PtERRs
DIRECTOR OP PLBLIC PROPERTY/BCtf.DLNG CONNISSIONER
Construction Debris Disposal Arfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S I50A.
The d s will be transported y:
(name of hauler)
The debris will be disposed of in
(name of facility)
,.�--
(add s of facility)
signature of permit applicant
(late
dahnvif J•a:
CITY OF SALEM
39
PUBLIC PROPRERTY
DEPARTMENT
:.
.Vwnf:X:rY:)x Krs n 1.
U k 4 ua 11C.W Asn1.Na I ON S I' HL:T • SAL lift,M.w 1S.Ua It si.] IS 0197'�
TcL:978-170-9595 • p.Ix.978.74C-I346 .
Workers' Compensation Insurance Affidavit: Builders/Contrac torsi Electricians/Plumbers
\ ) slicant Information Please P int Le ihly
Name lDusincsxlOrganirarinNlndwuluall
C(LL�L G Ci e-5 E
di I
city,slarc;/.ip � ��r7 � I'hune 0: �Uf Icy
��5
.\re you an employer'.' Check the appropriate box: Typo of project(required):
1.❑ I :can a employer with 4. ❑ I am a general contractor and l 6. ❑ New construction
ell (toY ccs full uiid/orP art-tone).• have hired the sub-contracturs 2, ❑m a sole proprietor or partner_ listed on the attached sheet. 7. ❑ Remodeling
ship and have no cmployccs These subcontractors have N. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
I No workers'cutup. insurance 5. ❑ We area corporation and its 10.❑Electrical repairs or additions
required.) fi icerx have exercised their
3.❑ 1 ;kill a homeowner doing all work right of exemption per NIGL I I.❑ Plumbing repairs or additions
Inysclf.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roufrepeirs� ��r
insurance required.) r employees. (no workers' 13. icir 4E/�'!/'7
comp. insurance required.)
'Ally apphcunt;hut chucks box 01 muss also till our the w-clion below showing Their w•urkuti cumpunsal policy inrinnutiun
I Iwmuuwnen whu m;bmil this anidavil indicating itky are doing all work mid then hire outside contractors must.ubmit a new alydavit indicating etch.
f,Mmuwus than chuck this box Mimi aochcd an addilion ll.r1ue1 shuwinu nhc name of the sub�contrwton and their worker'comp.policy infoannnun.
/run ml rrnpluyrr that Le pruridink lvurkers't•onpensurinn inturnncr jar wry carp/uyrer. Behnv is the policy and job site
iuf✓ruwliun.
Insurance Company Name: _.. ..
Policy is or Self-ins.Lic.r1: .__.. _._._ Expiration Datc:
Job Site Address; CityrState/Zip:
Amach It copy of like workers'coinpcnsation policy declaration pale(showing;the policy number and expiration date).
Failure Lo sccurc coverdg as required under Section 25A ul'IIGL c. 152 can lead to the imposition of criminal penalties of a
zinc up u il.5110.00 an r one-year imprisonment, as well as civil penalties in the furm of a STOP WORK ORDER and a fine
of up to S250.0 sla ainst like violator. Be advi.+cd that a copy of this smtc Bern may be lurwarded to the 011ice uf
llkCeltlgjiions I'the I A for insurance covcragu wcrilic.ktiun.
71f1o7her2,vb certifyir ler the pains and penuUiex oftlerjury that the infurination pro Pitted u cave is frrr and correct.
�_ Date,
Ofliciul use uniy. Do not write in this urea,to be completed by city or rolvn u/Jichal _ r
City or'I'nwn: - Permit/License N._.
Issuing Authority(circle iliac):
1. reward of Health 2. Building Department 3. Cilri fowu Clerk 4. Llectrieal Inspector 5• Plumbing Inspector
6. O4her
Crutactl'cnou: _ _ I'honc,Y:
Information and, Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emphrree is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity,or any two or more
rt the tvregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ul'an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
\lGL chapter 152, §25C(6) also states that "every statte or local licensing agency shalt withhold the Issuance or
renewal of a license or permit to operate a business or to construct.buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, NLGL chapter 152, sv'25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomwnce of public work until acceptable evidence ol'compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants ,
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of industrial
Accidents'for confimtation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to die city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the low or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of die affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Phase be slue to till in the permit/license number which will be used as a reference number. in addition,an applicant
that must submit multiple penniu'Iiceise applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affiduvit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lie office ice tit Investigations would like to thank you in advance fur your cooperation and should you liave:my questions,
please do not hesitate to give us a call.
The Deparnnont's address, telephone and fax number:The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofllee of Investigations
600 Washington Street
Boston, MA 02111
'Pei, # 617-7274900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
;t ,;.ed ;- i,-us www.mass.gov/dia