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179 LORING AVE - BUILDING INSPECTION The Commonwealth of Massachusetts r(° Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEb( C' Revised kfar 2011 xu Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section,For'Official Use Only Building Permit Number: a. (, Building Official(Print Name) Signature Date SECTION 1: SITE INFORiN 1.1 Property Address: 1.2 Assessors i ap Br Parcel Numbers --� Ler�n4 AV P ;1Ije 1.I a Is this an accepted stree . yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 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❑ SECTION2:: PROPERTY'OWNERSHIPi- 2.1 Owner'of Record: Name(Print) City,State,ZIP Ave M-74q-24i/o 0ihanoCi&kpV11 ecv No.andT Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WOR.W(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': ilira c le4 a n rl S.c-,- i Lag:ice -,+pyl fear ;^ V \ SECTION 4: ESTINLATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only-, Labor and Materials 1. Building $ I. Building Permit Fee g Indicate how fee is determined: ❑ Standard,City/Town Application Fee 2. Electrical 5 ❑ Total Picject Costi(Item 6)x multiplier x 3. Plumbing S Li Other_Fees: S__ t. Mechanical (11VAC) S List: 5. Mechanical (Fire $ Sn : ression) _ Total:\(l Fees: S_ Check No. Check Amount: Cash AmOuut I (. I'o tat 1'rnjcc[ Cost: 3 2 (� ('� j rJ ❑ Paid in Full ❑.Outstanding Balance Duc: SECTION 5: CONSTRucr1ON SERVICES 5.1 Construction Supervisor License (CSL) License Number Expiration Date Name of CSL I folder List CSL Type(see below) No. and Street MS,,id - Description icted Buildin s u to 15,000 ted 1&2 Fmnil Dwcllin City/lrown,State, ZIP Covering and Sidin uel Bunting Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(MC) flIC Registration Number Expiration Date I IIC Company Name or IHC 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 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 Fentering r of the subject property, hereby authorize y behalf, in all matters relative to work authorized by this building permit application. 's Name(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION g my name below, I hereby attest under the pains and penalties of perjury that all of the information n his application is true and accurate to the best of my knowledge and understanding.'s or r\uthorited ,ent's Name(Electronic Signature) v D�uL e NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty find under MAIL. c. 142A. Other important information on the HIC Program can be found at tt %vmiasi.,,uv:/oca Information on the Construction Supervisor License can be found at uwo.ntass.cu IdL 2. When substantial work is planned, provide the information below: Total floor area(sq. ff.) _ _(including garage, finished bascmendattici, decks or porch) Bross living area (sq. ft.) _ Habitable room Count Ntunberot'fireplacci Number of bedrooms ._----_------- Number of badtrooltts Number of halEbaths _ IN'pe of heating system - --_ _---- -_--_. — Number of decks/porches ——-- -- I'Npeofcoolim" sy;lent Enclosed (1 en I. "fnt'd Proioct SlJtl',tic Lootllge" 11my be sllb'ititiltod ror.•fnLd Project Co;t' CITY OF S.ULE.bf PUBLIC PROPERTY DEFAM. LENT w9Oe t xl WUNI"GWu Irld"• ULM^V WAOAIMIM anr'e Mi.93.7119f1t •r..a 97&746984 HOMEOWNER LICLNSS E.CY.Mnj0V Pteaw Trial Dots a 4-?,o-17S job Ucadoe 1:79 LA m- yic (we m�RoOwnerAddress s m.. e_ r 77$ a4�4"^ c.>,t4— Home Owner Telepbaeo q 7,�d - -7 4L4-z q- Present Maiilfng Add4ow )79 The current exemption of"Homeowners"was extended to inch&ownw-occupied dweUtngs of two Units of tear and to allow such homeowners to eagags an individual for hire who does not possese a license provided that the owner acts as suptiMaot. 139FINMON 01 HOMEOWNER Persons) who owns a pared of laid on which hdndts resides or intmrds to reside on which there N6 or is intended to be a one or two Qrmily dweWng, attached or detached strssctures 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 O®vial,an a form acceptable to the Building Ofl9cial, that helshe 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 re�uladona The undenigned "homeowner"certifies that hNshe undenrands the City of Salem Building Department minimum inspection procedures and requirements and that he/she Will comply with said procedures and re uirementt HOMEOWNERS SfGNA-rLRE APPROVAL OF SUILDNG ViSPECTOR �Mw Sce other side far state code 1 CITY OF S'U.E.NI, NL LISSACHUSETTS ! S s�,,j< ©I:tLD(:1tGDEP.1R71lEVT ' l 30 C4.ISHLYGTON STREET 1A° •, FI-OOtt �h TEL (973) 745-9595 Ki\[BERtEY DRISCOLL F.ILX(978) 7.10-9345 �bUYOIt THOSUai Sr.PIERRs DIRECTOR CF PI;IILIC PROPERIY/BCILDLNG COSL\(ISSIO ER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit ik is issued with the condition that the debris resulting from this woric shall be disposed of in a properly licensed waste disposal facility as defined by MGL c l 11, S I50A. The debris will be transported by: (name ut'hauter) The debris wi11 be disposed of in e (name of racaity) (address o r Yaci l i t%) signature eepermit pliant wl- 3 0 -13 hate -- 1