238 LORING AVE - BUILDING INSPECTION (2) f
The Commonwealth of Massachusetts
Board of Building �g Reulations and Standards FOR
�y MUNIC'IP:ALI'I'Y"
Massachusetts State Building Code. 780 CMR, 7"' edition USE
his»:9
/\ Building Permit Application To Construct. Repair, Renovate Or Demolish it RcrLrrrl Junuur)
l(�\� One- or Tn o-Family Dwelling 1 1, 2008
'^ This Section For Official Use Only
Building Permit Numb Date Applied:
�Signature: i3, wig
.
\vn\ Building Commissioned Inspector of Buildings Date
�\ SECTION l: SITE INFORMATION
1.1 r 1.2 Assessors ap & ParcepLA J orinq ( v i nbr O-7
Lla Is this an accepte street? _ O
yes no_ Map Number Parcel Numher
1.3 ZgniI g Information: 1.4 Property Dimensions:
Zoning DistrictProposed Use Lot Area(sq fit Frontage(it)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Requited Provided Required Provided
fV
1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'?
Public � Private❑ Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2A�Irll Owner'ofRe ordLOSQ
C o
n /I !///�S 2,39 Lo �►rl VQ.
hael L
Nam (Print) Address for Service:
L- ( gi 7S 7L1 bZ-3-7 -
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief Des,ription of Propo ed Work': F , - a l C
— — VT ai
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
L Building $ 20, 000 1. Building Permit Fee: $ vindicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ 600 ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ q,00Q 2. Other Fees: $
4. Mechanical (FIVAC) $ -7 00 List:
5. Mechanical (Fire
Suppression) "fatal All Fees: $
N � � Check No. Check Amount: Cash Amount:
�
o. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /,j'/A
1/prne oamel^ License Number Expiration Date
Name of CSL- Holder List CSL'Type(see below)
DescriptionT c
Address Q to to CuI Ft,)
i3gZ�rtA Sa / R Restricted 1&' FmnilyDwclline
Sign . M Masonry Only
✓✓///�/2� RC Residential Roofing Covering
Telephone \VS Residential Window and Siding
q7g �(/� LZ 7� SF Residential Solid Fuel Btunine A>>li;mre Inswllaiiun
[ [ (J D Residential Demolition
5.2 Registered home 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. § 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
I, /I ome O(.Il4 as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work auth ]zed by this buildi g permit application.
Signature of Owner Date
SECTION 7b: O/WNEW OR AUTHORIZED AGENT DECLARATION
wi°I, AC // (,(i' C l` o4ls - , 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
behalf.
Co ZL .Z�US
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 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 IO.R6 and 110.R5. respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished base mendattics.decks or porch)
Gross living area (Sq. Ft.) Habitable room count 6
Number of fireplaces NA Number of bedrooms 3
Number of bathrooms Number of half/baths l
'Type of heating system Z9X1S i� Number of decks/ porches
Type of cooling system IVII Enclosed Open
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
C1TY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
•.v�t•1 d �a9L �Ay�`_
]l\N• 13.ar.V Rom.:JMf 3{t{T t♦�li 1�1Q Y�lr''M•t 111 i�9
Tn.JOW46AM •f.ut IJ40*64
Construction Debris Dbposst Affidavit
(requital lbr all dsaaolitloa and movatiau work)
in mordswo w ith the slats a don a(dw Stott Huildins Cods►730 cW11 saetias l l 1.3
Debris.sad the provisions otMtGL s 406 S A
8yildin3 reretit I _ is law "wilt tht condtdoo dtss the debris ra dtkg hot
,his wort shall bt disposed at in a propwty lismssd waste disposal &cility as daMa l by%t(]L s
ttt. s15"
The debris will bs transported by:
Vyor05ide- COrtlol7 roc.
rho dcbds will bt disposad all in :
,5cu�aNjp_coH led .Salem
lSt.au ui fxd:ty)
Z�/Apps -
CITY OF S.XLEM
PUBLIC PROPERTY
DEPARTMENT
K110�w Nw ry,
Mnraa t�wwvurw-ra+s�sr•suFxSl�a'SBrRot970
7V:978-73S-9S9S 9 FAX:978-740.994
HOMEOWNER LICENSE EXEMPTION
Please Print
Date 211110 g Job Location 2-38 to,--+hy A✓e Safeei Inf 01916
Home Owner Address Sa-"e-
Home Owner Telephone 67 7$ 7• i/ —6Z 3 -7
Present Mailing Address scywr e-
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.
DEFINMON OF HOMEOWNER
Pason(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 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 andd reeqq/uirements.
HOMEOWNERS SIGNATURE /%%i ,/
APPROVAL OF BUILDING INSPECTOR
See other side for state code