175 LORING AVE - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
CITY OF
Board of Building Regulations and Standards RECEIVED; ;
Massachu.etts State Building Code, ?8n�`ftCTIOMAL SERVi ` SMar
ALEM
Ulf � �2evisedMar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling 101h MAR 24 'A 1 31
N This Section For Official Use Only
' Building Permit Number: Date Ap 'ed:
J Wt.« :, ` 3 zY 4
Building Official(Print Name) Signature Date
1
SECTION 1: SITE INFORMATION
1.1 Property Address: qq 1.2 Assessors Map&Parcel No gqers
17,5 Z 6fir10 A Ve �au�en(�/�/T el o I - o� Og— b
1.1 a Is this an accepted street9 yes_ no Map Number Parcel Number
1.3 ZoOt Vormation: 1.4 Pr •ty Dimensions: ��
(� a
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 'rO�wne`ARecor(IF M� a l 9�Q
Name(Print) City,State,ZIP
t zy
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ld Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': Ale '—
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 5LL7D lb 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 $ D1v 2. Other Fe $ -/O� �
4. Mechanical (HVAC) $ List: CXhes: /��1�� r �
5. Mechanical (Fire $
Su ression Total All Fees: $
/ Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ G bTJO ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
a5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSI.Type(see below)
No.and Street Type Description
U Unrestricted(Building s up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
Cityi t own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SP Solid Fuel^uuruing Appliances
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 i!I r 0 in the de...a!ofthe Issuance of the building pernit.
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: OWNER' 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 in this/application is true and accurate to the best of my knowledge and understanding.
kg
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
\ NOTES:
I. 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.gov/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 SALEM, MASSACHUSE TTS
BUILDING DEPARTMENT
120 WASFHNGTON STREET,3" FLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9946
MAYOR THomAS STAERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONSUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Job Location 7 // AVM
G
Home Owner Address l z� p �. r7
Present Mailing Address
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 that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides 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 form 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 understand the City of Salem Building Department
minimum inspection procedures and requirement an that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF SALEg A ASSAaiLsE m
BtnDmDEPARnfem
120 WA9MC7MS7REET,3=FLOOR
Tit.(978)745.9593,
FAX(978)740.9846
KtMRFRi FYDRISODLL
MAYOR THCUM STREW
Construction Debris Disposa/Affidavit
(required for-all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CAM, Section 111.5 Debris,
and the provisions of MGL c40,S 54; Building Permit d is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris w�illll/be disposed of in:
/ i �S
e_
(name of facility)
(address of facility)
Signatur pplicant
Date