183 LORING AVE - BUILDING INSPECTION (2) The C'onmtonweal(h of MlISSIM1lISCt(S
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR S,\LL\f
ti1, Re i.ved,l Lv 2011
.,..
Building Permit Application To Construct, Repair. Renovate Or D it S a
One-or Tuv-Fumllr Dwdlhttr
This Section For Official Use Only
Xth
it Number: Date Applied:
ial(Print N;une) Sigl [)at
SECTION l:SITE INF RNIATION
ddress: 1.2 Assessors Nlap& Parcel Numbe
<nv� q.cccepted street?yes ✓ no M1f+tP Nwnbcr Purccl Number
1.3 Zoning Information: Li Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.aU,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check ifes❑ sal Municipal❑ On site disposals) ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 O�v'nerto/Record:
(vlohcl ch ndlerola7o
N;une(Print city.State.ZIP
v 1 3 Lor,v.4 Ave. bo3_2 N�f-6ot� _ -Fcl,.�-�c�IQ c 73 L a boon Ce. %
Nu.and Street —4 Telephone Finail 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.❑ Number of Units_ Other ❑ .Specify:
Brief Description of Proposed Work':
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and \Luerials) Ofttclal Use Only
I. Building g To o p 1. Building Permit Fee: S Indicate how fee is determined:
'. Electrical g ❑Standard CityiTosvn Application Fee
❑Total Project Cost(Item 6)s multiplier
1. PIwnhing S 2. Other Fees: S
). .M"ll:mical III\'AC') S Lis[:_,__
?. Mechanical (Fire
/ - � Suvncsiion) g Total :\11 Fees: $----- -------- ------- .-
rrd// Check No. C'heckAnwunt: _ _ C;uh :\motnu:
Total Project Cost: S ,Soo O ❑paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUcTION SERVICES
5.1 ('onstruction Supervisor License(CSL)
License Number._.__ F%pirnion Dale
N;unc WSI. ,taller -- -
Lisi CSL 1)pe,see h¢lowl
.B PC Description
NCI. and Slral
l l I nrestricted(lluildin�s Ib to 35.0110 ul. Il.l
VD:1
Reslrictcd M2 Fanlil Dwelling
C'il%i tots n,Sl;ue.ZIP MasonryRoolin C'overinWindow:Ind SidinSolid fuel ,turning Appliances
Insulation
mailaddressDemolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number E%piroion Date
IIIC C'onlpan) Name or IIIC Registrant Name
No. and Street Email address
City/Town,State,ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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........... O
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) Dale
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
•ontained in this application is true and accurate to the best of my knowledge and understanding.
�(oI 0 CIL�Llcljer to /70 /1(
Print Olt ner°Cur:\uthorizeJ,�gem'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 Hume Improvement Contractor(HIC) Program),will rro have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be round at
k otI I Information on the Construction Supervisor License can be found at I>sy nsls� ^.,k Ip,
? W'hen substantial work is planned, pro%ide the information below:
Total Iloor area lsy. R.) ________(including garage, finished basement a(tics,decks or porch)
Gross living area I sy. It.l ------ - Flabitable room count
Number of fireplaces Numher of bedrooms
Numher ofbathrooms Number of half baths .
1')lie of heating S' sAcnt .. ._ - _ .-- Number of decks, porches
I%pe of%:oo1illg S%Steil) _ - _ I'Ilclowd - -
I
it. "folal Project Square Footage- may he Substituted thr''I'Mal Project C OSC
1 N
CITY OF S.UX.N1
PUBLIC PROPERTY
DEPARTMENT
Nwvd 130 7ADdMG OM MANY 0 SAtlK M SMACIft SWM 0t9V
HOMEOWNER LICLNSB EXEMMPTION
P1eaN Ftrlat
Date io /z0 � 1t
Job Locadost 1 6 3 t o r, q ✓c Se I e 014 7 0
Home OwnerAddteaa 1b ,3 Lor•h Ave- 41r ,2t 0(g70
Home Owner?elepilms (-0 3 _ Z -1 -6 0 1 -f
Pmamt MnHng Addreo 0 3 Lo r,�-� Vie. SE le M� a iY 7 a
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to eagags an individual for
hire who.does oot possess a license,Provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Perwn(s)who owns a parcel of land on which hdd w resides or intends to reside6 on
which there is, of is intended to be,a one or two famiily dweilfng, attached or detached
stmcnares accessory to such use ad/or farm structures. A person who consaucte more
than one home in a two year period shelf 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 bylaws and regulations.
The undersigned "homeowner"certilles 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 requirements.
HOMEOWNERS SIGNATLIE
-kPPROVAL OF BUILDING INSPE
See other side for state code
CITY OF SM.&M, Akss.tcH us ETTS
BLUXING DEP.IR T\tEr T
120 W.1SHNGTON STREXr. }iO FLOOR
Ttt. (978) 7�3-9595
KIAMERE Y DRISGOLL FAX(978) 140-9846
.tiUYOA Dicim u ST.PMUR
DIRECTOR OP PL8[.IC PROPERTY/gt:MDLYG CObLNISSIONER
Construction Debris Disposal Afttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l l 1.3
Debris, and the provisions of MGL c 40, S 34;
Building Permit N_1 is issued with the condition that the debris resulting from
1 11, S I SOA.work shell be disposed of in a properly licensed waste disposal facility as defined by MGL c
I
The debris will be transported by:
t7
Game urhauler)
The (debris will be disposed ofin :
(n�maorfudity)
�� 4 --I Nip,
(,ddnes or'r ci iy)
vynamreofpermit�pp6cmt _
O ,I�ta