150 LORING AVE - BUILDING INSPECTION What is the current use of the Building? units?
Material of Bui{ding? If dwelling.how marry
Wilt the Building
Conform to law? Asbestos?
Architect's Nam•
Address and Phone
s Name 3 'l1(�
Medwmk'
Address and Phone ! �/3 vHIC Registration fs
Canatruetiort Supervisors ucense 01
Estimated Coat of Project Estimated
Permit Fee Calculation
- OD Estimateded Cost X$71s1000 Residential
Pennit Fees
_ - . Estimated Cost x sl usl000 Commercial-
An -
Additional s8.00 is added as an
Administrative charge.
Make sure that all fields are properiy and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above s
specftatkm. Signed under penalty of perjury
Date
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PUBLIC PROPERTY
DEPARTNI&NT
uwra 13Ovr,.w N=w bnmhT•
SNUK WASfA01{:Sl1lS 01970
T EL M745.9S93.Fjm M740.9W
APPLICATION FOR THE REPAIR. RENOVATIO&CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDIN
1.0 SITE INFORMATION
Location New ti 6 e f Suilding;
Property Adiftsw-
P WWV is located in a Consarvadon Area Y/N /_Historic District YIN—11
2.0 OWNERSHIP INFORMATION
7.1 Owner of Land '
Name:
Address:
lS 02f -
Telephone: 2
3.0 COMPLETE THIS SECTION FOR WORK INV7Storiee
NGS ONLY
Addition ng
Renovation Number ated
Change in Use Demolition gApproximate year of Area per atedconstruction or renovation �DD,of existing building
Md Description of Proposed Work:
— -- Mail Permit to: 0
7791
4 AGO RD ,' I I a l _ A: F I 06 07
«` ..' 7NL CERTIFlCATE IS 1,NO R AS A MAn'ERR OF tNFOAM CA E
PToouOEL ONLY ANO CONFERS NO NIGHTS UPON THE CERTIFICATE
LOHR INSURANCE AGENCY, INC. HOLDER:THIS Cl3fflflCATE DOES NOT AMEND, ATTEND OR
111 state Street A 14OLDi THE COVERAGE AFFORDED BY THE POUCt '
COMPANIES AFFOROINO COVERAGE
MA 02109- CCMPAW
Holton
_ A AIG INSURANCE COMPANY
(617) 227-1660 ( ) CCLPAVT
P - B ESSEX INSURANCE COMPANY
A. B. CARNES, INC.
30 ARROWHEAD FARM ROAD 00teAN1
c ZURICH INSURANCE COMPANY
gOXFORD MA 01921- CWPAW
(978) 35-1356
ImsuFiEDNAM THIS 6 TO CERTIFY TFORTHEPOUCYP
NATTME PCUCIES OF INSUMNUE I,IGfEO BELOW HAVE BEEN M EDTO THE 07HER DOCUMENT V HEREEPECf To WHICH THIS
W IS tS T L EFMFY 7S'TANLMI'7G A NY REQUIREMENT,TERM OR CONDITION OF AM' T
MDICA CATS MAY BE ISSUED OF MAY PWTAITK THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE 7£?.AiS�
EXcUJSLONS AND OONDMONS 0=SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN Ti�UCEO BY PAID CLAIMS.
roUvvEFFHCTN6 Pouffowm7m UMNB
co -Tymol!wjxtmE POLICYNUIim" OXmpW1pDrM '
A RAL $2,000, 000
B O°°°s"LY11c& 03/18/07 03/18/08 I'mucm-cOAwArAOO $2.000 000
X DDASIdNL�+EraLLlAarry 0530291E PenSCKnL.EAwcuAn $1 000,000
N. CLAM MADEQWCLP EApfOGCUW@CE 11,000, 000 '
:. OMh3TsaooanRlciCRS PPFS FM OAwAE Wn Om RbT E
MEOEro PPPPwPMI $
C w+OYOeSEDA807I+ OpyraPassWAIEL®Bf S
XWALM 379040-00 12/08/06 12/OB/07 _.
X AaoxMMAUIas pmwo °100000
X onplMUPOA M8
X HsmAmns QcW.Wm 300000
PPOPERTYDWAGE s100000
/ AUTOONLY-FAACCNA+T
IUIT S
OARAINOAB / ( / OTFaIRTWNAUTOOM.Y:
PNYAl110, LAWHACOMWr S
FPCMaavaAtT+cE 5
O06lTNN a6RdJ1 AF[{Da- _ IA (fia- 1, a.a+ yt �'`a
X Tc
p` uAa m � 03/31/07 03/31/08 v EAOIAWOENr s100 000
0350278
X !V0 p,OCEAM-PODGY JMIT s500 000
IMPaonwEVON
PAATPs>�xEcm� Lac goa .EAEmc�-� e100 000
CFFCEWARE .
o,Ha+
t>EscrePLroN oc oroumN°nacAnDNs mla���
ALL OPERATIONS USCAL TO THE BUSINESS OF THE INSURED
MOVE E9me
SHOULD ANY OF 711E. . •ov rouct3fBe WICB=Ocroft THE
- EYPMIM DATE IVOMOF, THE MUINO COMPANY TOLL ENDEAVOR TO MAIL
1 Q DAYS T ITIEN NOTICE TO TI1E CEROFICATE NOum NAMED TO TIE LEST,
um TO. -"�pOT9CE° I OSUGATON OR LIMNTT
OF @ILO O /TINE AN Elm OR MRLS.ENTATIY
fit.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ansnttt=oaeo=
L%VM 120.�maetaastneer.sa><ne.lt�raas zs01970
TM 97b7t,MM.FAX SW4 U%
Worltara' Compeelsadam I>asonsee AtUaft BWMerWCo
ADUHnnt Informaden pI d 1Mw.r..te.l.r
Name(
Address; D Iz—
o
CityiststdZip: Phoned{
Are y" yet}C1uk tYs ayproprfala Dw Type 1. I=s employer wuY 4. 13 I am a good contractor and I K �
employees(ihB and/or pas j dm4e haw hired the■b cograemn d 0 Now Constr0ction
2.0 l am a soht psopeieeor r permse. lived an the mtwbw chest 8 7. ❑Ramose ft
ship and have no amployees These md•000Yaetoea haw fl. 0 Demolit6o■
working he me is any capacity. workers'camp.mnuaaa.
(No waclra'Comp UWWanp S• 0 we ars a earprmin sad its 9- 138atilding addition
3.01 h meoarna otIIcros have mrecised their 10.0 Electrical sewers or additions
wing all work right of wampum par MGL 11.0 PInbing mp dm or additions
myself No wosken'Comp 0. 152.11(41 and we haw no 12.Q.1tooteepain
insurance required)r amps Din wad ma' 13.0 other
comp insurance required)
;AaW Wdeam■ndoft box.tnodoe fin am■e"Was takeamblests, k■s'
}1mYaalselerYe aa�IYY a�Ya e�■ealYa■p�M drtq d aa�rt V ilia)artltesrraowe eW�e east alLire rCoesesaaMrrsYwtAlehare�tirr�Mradditlesddrwdratr�Aea�eafAer�aaasesesraiaak�art�e'saeF harass"
/ar an awoloyer that 4prorldlirj panthers'cowOentedcr■hurrowCejor lelerwadaa my amiskyess. R*kw brie sbb
P�7'end/a+
Iruumoce Company Name:�LSL(
Policy#r self-ins.Lic.
Expiration /-
lob Site Address ciq�statelZip
Attack a copy of the workers,Campessstio■poliky deeLratk■page(showing the policy number anal*zpkrad"data}
Faihue to secure coverage as required under section 25A of MGL a. 152 can lead to the impoaidodon of criminal pamattias of a
fw up to S I.300.00 and/r one-yea impriaonme�as wen as civil Pamir!"in the form of s STOP WORK ORDER and a fine
of up to 3250.00 a day aping the violator. as advised that a copy of this statement may be frwarded to the Offte of
Investigations of the DIA for urge veriRatics.
i+wraoa
/Jo hereby oral under and pana/dq o/Oar/suy Cher the/njoracallowProvlda/abort 6 aw and tarred
Phoru As �3 5— l��®
00c d use on1A Do not writs in rhlr ereq Is be eostpldi/!gr tilt or pawn oQk/a(
City or?ow■: Permluticanu N
Issuing Authority(circle one):
1. Board of Health 2.Building Department ).Ciryfrown Clerk d. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone ih_
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
�;urrnLEr nnisc:iaL.
\LtYO1: 120 WAij aNC.I ON STREET •SAL F.M.MASSACHL SL ri S 0197:
Tr.L:978-745-9595 •FAX:978-74G9846
Construction Debris Disposal Affidavit
(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 # __,.._ 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 150A.
The debris will be transported by:
(name of hauler)�
The debris will be disposed of in
Pey�_ �v
(name of facility)
laddress of Luc;Iity)
si--uatwc of penni lwl ant
s �y5
._ ,late —_