214 LORING AVE - BUILDING INSPECTION (2) The Commonwealth of Mdssachusetis I OIt
\1 BOUld of Building Rceld itiuns :old Standards
l ; %IaSSaih Code,State Building ode. 7S(I (AIR. 7"'editiolt \II MIL ll' \III l
1 q_ ,. P SI.
or\ � Building l'crmit Ap ' )u`nt To T(tr,'tl!u,ulr Du cllpltux»ate Or Demolish aK, �,,,J.l,un,�n
"I'his Section For Official Use Only
Building Permit Nl lb _ Date Applied:
BuddmI ('ui unis+i i v ,.'ectur ul Buildings Uale
SECTION I: SITE: INFORJI VIA ON — _ --- -
1 1 Property .\ddress: 11 :\ssesson flap & Parcel Number.
I la Is this an accepted street , yes no Map number Parcel ,\'wnbcr
1.3 Zoning Information: IA Property Dimensions:
Zoning U 'I, Proposed Use Lot Arta(sq III Frontage iftl --
1.5 Building Setbacks (ft)
j From Yard Side Yards Rear Yard
! Required Provided Reyuued Provided Required Pn �idcd
I
1.6;Water Supply: (M G L c 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'.'
Pub ❑ Private❑ Check if yes❑ Municipal ❑ On site disposal syslcm ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Record:
M C1 Psi 2SM-- --21 ,14 V') (zl A-)& ✓YVt SA(
Namc Print)�p Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (cheek all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addino, ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specily:
Brief'Description of Proposed Work
':
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: I
I
tem Official Use Only jl
I Labor and Materials)
S L Building Permit Fee: $ Indicate how fee a determined:
❑ Standard City/Ibwn Application Fee
$
❑Total Project Coat (Item 6) x multiplier x _
S ? Other Fees: S(HS'AC) $ List: (�(,
i. Mechanical (Fire S
Su ress ion) Total All Fees: S
. Check No. Check Amount: _ Ca,h \m„unl:
o rotal Project Cost 0 Paid in Full 0 Outstandme Balance Doc:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
--. _— I..Icen,e N'umher
.\ame St.- IIuIJer
Lot CSL I)IV Nee helu„1
( l Il l'C,1r1,led nl r I oth)( 11 I'L
R Re,u'Ielad 1.1r2 T.unilk U„elhnc _�
Siunaulr--- \t \t:uann dr R al
C' Revnual Rootitle Can
telephoto• \\S R:,iJ.r.lul \1 inJo\, .inJ iiJuie_
SF Re,1deull.lj S,-1ud I'•.lel ISuuw!e \ �,iL.iu.c In.LilLu i ii yl:
D Re,idcnn.J Demulwon
5.2 Registered Home Improvement Contractor (IIICI
HIC Cnnlpayry Name or HIC Regouant Name Regnlrauon NumVi _
\ddress
Fspirauon D;ee
'i�gnutute T.:=.cphune
_—_—
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed :old submitted with this application. F:ulute to pork Ide
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
I• _._ _ as(T.aner of the whl=ct property hereby
authorize ____-._ to act un my bch:dt. in all matters
lelatve to \vurk authorized by this building permit application.
i
Signature of Owner Date
-
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
L AAAP.K Spa ' , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
I behalf.
M\9JZx � --
Pnn a < I/J2�`T7'�
Siel azure ul Owner ur Authorized Agent Dater-r I
(Signed under ibe pains and Enaltiesof perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or ;In owner who hires an untegi,tered ctm(rach)r
(nut registered in the Hume Improvement Contractor(HIC) Program), will not have access h, the :ubltruion
program or guaranty fund under M.G.L., c. 142A. Other important information on the [if(- Program :md
Construction Supervisor Licensing (CSL)can be tiumd in 780 CNIR Regulations 110,R6 and I IU.RS, respectl,ely.
2 -When ,ubsiantial work is planned, provide the information below:
Total flours area)Sq. Ft.) (including garage. finished baselnenVatucs. decks or putch)
I Gross livmg area ISq. Ft.) Habitable room count
Number of fireplaces Number fit hednu in.,
Number of hathrooms Number of halt!halh,
I\pe of heating system _- Number of lc,kN/ por'hcs
I s'pe of c0011110 N,,N(em — I:ncl\�,Cd _ Opl•Il _ ... -__- _.
1 "Total Project Square Footage" tn:v be xtb,ututed for Folal Project Co,t-
CITY OF SAIEM
PUBLIC PROPERTY
DEPARTMENT
K11d�Lry
%IAVM 130 WASHINGTO1A STREET•SA'yt WHACK SETTS 01970
._ TEL 975.74S-MS* FAR;979-740.964
HOMEOWNER LICENSE EXEIMMON
Please Print
Date`
Job Location 2 (L4 L Q01JJ:� XV6 SAC TAAf\
Home Owner Address "TA M1,
Home Owner Telephone !i�48
Present Mailing Address
i
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.does 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 dwelling, attached or detached
structures accessory to such use and/or farts 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 fort 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 and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code