180 LORING AVE - BUILDING INSPECTION 1 �
fhe Commonwealth of Massachusetts -- - - - — -" —
�11✓✓ Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR A
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Building Permit Application To Construct, Repair, Renovate Or Denwli a
Otte-or Trvo-Fcnnily Du e llhgg
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Nane) Signature
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map.@ Parcel umb s
1.la Is this an accepted strew?yes no Map Number PaIVNUmber
1.3 Zoning Information: 1.4 Property Dimensions:
7. AGO �10
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
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 131� Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal C•Y(Sn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wgerl f Recor • /
N:une(Print) City,State,ZIP
No.and Street "felep one Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ FE.xisting Building Cl Owner-Occupied V I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify: ,�Gt/�
Brief Description of Proposed Work:
C T3ay.r :nr C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building S Z��� 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'([tern 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (11VAC) S List:_
5. ,Mechanical (Fire S - -
Suppression) To[al All Fees: $
Cheek No. Check Amount Cash :\mount
---6. Total Project Cost: S ----
❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Fxpirnion Date
Name of C'SI- I lolder
List CSL Type(sec below)
No.and Street Type t Description
LI Unrestricted(Buildings up to 35,000 cu. It.)
R Restricted 1 2 Fartil Dwelling
C'itylfots n.State.ZIX -M Mason
ry
RC Rooting Cmeri
WS Window and id
SF Solid Fuct/tfurnin&ppliances
I Insulation
'rcic hone ['mail address D Demolition
5.2 Registered home Improvement Contractor(HIC)
IIIC Registration Number Expiration Dale
IIIC Company N:nnc or IIIC Regi ante \
No.and Street No
address
City/Town.State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 6 25C(6))
Workers Compensation Insurance affidavit must be completed and submitte wit 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 AUTHORIZATIONTO 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.
1 tint wner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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 ' true and a rate the best of my knowledge and understanding.
t
Print Owner's or,\uth cd ,unc(li uric.Signature) Date
NOTES:
1. 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 Horne Improvement Contractor(HIC) Program),will riot have access to the arbitration
program or guaranty fund under M.G.L.c. I42A, Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at god\% pciss.yo� 'dp_
2. 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 Isq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half.'baths
1)Pe of heating system Number of decks, porches--
-- --------—
--
I)peofcoolingsystein Enclosed
3. "rotal Project Square Footage"may be substinned for"total Project Cost"
CITY OF S.V..E.Nt, 2UNSSACHUSETI'S
Bt:tLDL%4G DEPARTMENT
110 W.,wimGTON STREfiT, Y0 FLOOR
n!L (978) 74S-959S
FAX(978) 740.9846
KIJtHERLSY DRLSCOLL
MAYOR 7H0aua ST.PMR"
DIRECTOR OF PLaLic PROPERTY/at:aMLNG CMDUSS[ONER
Construction Debris. Disposal Afridavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
Ns work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
�n 6''� ���,
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signs a mit applicant
date
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CITY OF SM.E.11
PUBLIC PROPERTY
DEPARTIMENT
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HOMEOWNER LICENSE EXEMPTION
Pleaw Trltat
lob Location ,/:O
Home Owner Addreaa rig c_
Home Owme Telephone �i �,7Gf
present MaftS Address _ s—iz ,
The current exemption of"Homeowners"was extended to include ownw-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not posaeae a Hcewr provided that the owner act@ as supervisor.
DEFINMON OF HOWOWNEB
Persona) who owns a paned of land on which he/she resides or intends to resider on
which there is. or is intended to bsr a one or two &milt'dwelling.attached or detached.
structures accessory to such use and/or farm structures. A pawn who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner'shall submit to the Building Otllcisk 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 regulsdon@.
The undersigned "homeowner"certiftes that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
Will comply with said procedures and requiremcnts�
— Z�:�
HOMEOWNERS SIGNATURE /
APPROVAL OF SUILDIYG INSPECTOR
See other side for state code
I