198 LORING AVE - BUILDING INSPECTION DThe Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
j Massachusetts State Building Code, 780 CMR, 7ih edition Building peps
Building Permit A on To Construct, Repair, Renovate Or Demolish a
OneI or Tiro-Funtily Dwelling
his Section For Official Use Only
Building Permit N r: Date Applied: 12, 10• U CZ>
Signature: 4 1 I U - 0 0
Building Co t
is+LJPInspcct of Buildings Date
SECTION 1: SITE INFORMATION
LI Property Address: A Je Su� 1.2 Assessors Map& Parcel Numbers
G/ Lcri% r �vtt /hA-
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) 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 Owner'nof Record:
�dN n N C . r'4{DtRrtri �"/ p L6f i✓1G. rT✓e • �a-I�Ni� /'/�
Name(Print) Address for Service:
Qw tC - FA/-ti-
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ rExisting Buildin:0 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify:
Brief Description of Proposed Work': i-s 1-guo �l of Sf'X Q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
Labor and Materials y
I. Building $ /ZOO /jam, 1. Building Permit Fee: S Indicate Idetemined:2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
6. Total Project Cost: $ 12�^j , pO Check No. Check Amount: Cash Amount:
❑ Paid in Full ❑ Outstanding Balance Due:
M�`1 ( Neu srt, Iz n /E1>-AF-CVD C-7
SECTION 5: CONSTRUCTION SERVICES e
5.1 Licensed Construction Supervisor(CSL)
+• License Number Expiration Date
Ngme of CSL- Hpider List CSL Type(see below)
T Description
Address U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin -
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Rome Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
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........... ❑
SECTION 7a: OWNER AUTHORIZATION TO 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I L. Fp.le,r.-- ,as Owner or Authorized Agent hereby declare
that the fitatemems and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. I �^
Print Name
Signature of Owner or uthorized Agent Date
_(Signed under the ains and enalties of perjury
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and 110.115, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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"
I
CITY OF S.UEM
PUBLIC PROPERTY
DEPARTMENT
NAVOR 130wAMDWY Ns7fesT•Suea6..%UWA0 sens01970
lm:972-745-95"* Fnz 97s•740-964
HOMEOWNER LICENSE EXEMPTION
Plea"Print
Date I Z-!o-O 8
Job Location 1 R V Lp r ,�g
Home Owner Address 3 +-'i uc e.so a . flee-6ad,, , ryi,� e r9
Home Owner Telephone 5,e 88 0-t--z o 6 4
Present Mailing Address 7 A�(c t g s RA( PQat-c-e# rr6 a
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 who.don 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 dwellin& 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 procedures and requirements.
HOMEOWNERS SIGNATURE C- ,
APPROVAL OF BUILDING INSPECTOR
See other side for state code
{ '=" CITY OF SALEM
Ax PUBLIC PROPRERTY
D EPAxT?�tE1vT
12, AAil]IN(: ,IN S I I Ir # S.0 I M. \1.\.;\t iI ; -P) _
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit H - _ is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signart e of permit applicant
2 -/0 ow
date —__-.