179 LORING AVE - BUILDING INSPECTION (2) The Common vvealth of Massachusetts - CITY OF —
Board of Building Regulations and Standards
6 b
i SALCN
t /.9 Massachusetts Slate Building Code, 780 CMR Revised.tlur-'oll
Lb
Building Permit Application To Construct, Repair, Renovate Or D• o is a
One-or Tteu-Family Dn ellh g
This Section For O •'al Use Oil]
Building Permit Number: ate A plied: I
Building Otlicial(Print Nine) Signal
SECTION 1:SITE INF NIATION
.1 Property Address: 1.2 Ass ssors M; reel Numbers
A-�-19 'SA,- rtV
I.I a Is this an accepted s et?yeses(_ no Map Num x Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage Ul)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1_c.y0.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood"Zone?
Public❑ Private❑ Check if es❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
1 Owner of R,rrd: I n^ ,^
FOP( lrn 0 >1t 5t���}—�1�� OI c!
Name(Print) City.State,ZIP
17 R L Oye el y e 79t-5-' 3 -7 3
No.and Street 'relephone Emml Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Spccity:
Brief Description of Proposed Work':
i � � r II i6s/ IZ foof- c{PrK � r- �,F r _ C`
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and \lalerial s)
1. Building S o Cj D 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x_
3, Plumbing S 2. Other Fees: S
.1. \lechanic:d 01V:\C) S List:
i. :\Icthanical (Fire S Total :\II Fees: —
Su �ressionl
Check No. _Check Amount: ___Cash :\mount-__._—
G. Total Project Cost: S z O U ❑ Paid in Full 0 Outstanding Balance Due:
P �
SECTION5: CONS'fRUCTIONSERVICES
5.1 C'onstructimt Supervisor License(CSL) y
License Number --- lispiralinu Date '
Nnntc of C'SL. 1 IulJer �
List CSL T)PC(see below)
No. and Slrcel -- 1)pe Description
1.1 Unrestricted 113u61din-s ti l0 ---c 1. I3.)
City/town, Slate.LlP R Restricted l&2 Pantil Dwcllin
M Mason
RC Roulin Covering
WS Window and Sidin
SF Solid fuel 13 iming Appliances
_ I Insulation
Tcic hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Nantc or I IIC Registrant Name IIIC liegistration Number lispir:niun Date
No. and Street
[imail address
City/Town,State,ZIP Tele hone
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 W WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[1, as Owner of the subject property,hereby authorize
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 en eying my name below, I hereby attest under the pains and penalties of perjury that all of the information
contai ed in this application is true and accurate to the best of my knowledge and understanding.
t
Print Owner's or Authorize lgent's Name(lilectronic Signature) ,
Date
NOTES:
L. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
An
registered in the Home Improvement Contractor(HIC) Program), will nor have access to the arbitration
program or guaranty fund under M.G.L.c. 1 q'_A. Other important information on the HIC Program can be found at
wwy.fra.- .gp�oce i Information on the Construction Supervisor License can be found at t%oxN Ala;: -o� 'Jps
_' When substantial work is planned, provide the information below:
Total floor area(sq. R.) (including garage, finished basement'attics,decks or porch)
Gross living area(sq. it.) __ Habitable room count
Number of fireplaces-- —_ Number of bedrooms -- -------
Number of bathrooms
f.baths
l)pe of healing system Number of hal ----
Number of decks, porches
l)pe of cooling sy sleet.- -- - -— - --
-.. ------------_---_- Enclosed Open
i. •Total Project Square Footage-may be substituted for"Total Project Cost" -.
CITY OF S.UL F.Nf
PUBIIC PROPERTY
DEPARns. IENT
w.�G.ILL'A7LL
MArae ibeAYu"c7oM srwaar 9&MAK MAs{A0&SWM ON'e
11L 9'L719i9599•F.0 97L7469M4
HOMEOWNER LIMNSE EXEMPTION
PfeaN Font
Date n 7_J R -t 1
Job Loeadm 17 �-e 7—
Home Owner Addrew s e/ _ v c h .
Home Owarr?elephoae
Present Mailing Address 1.7 a j
The current exemption of"Homeownas"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a Hans%provided that the owner acts as supervisor.
DEFENMON OF HOMEOWNER
Pason(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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedure requ"nents.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR '7
See other side for state code