242 LORING AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
/1 !•ty ) Massachusetts State Building Code, 780 CMR, T°edition OF SALEM
Revised January
\ Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: 4 , ( c7
�' Q
Signature: 5J , T , ( O
Bui ding Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: L� 1.2 Assessors Map& Parcel Numbers
1.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 11) 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of oecord:
00-q1t7 f�U� ,�v r rt uGS 2�2
Name(Print) Add far Service:
,78 -7y�_ SZS`�
-Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ fteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other Specify: g0
Brief Description of Proposed Work: r,6 '
/r/it r✓
i .E4
a U dCi
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard Citylfown Application Fee
2. Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S )
4. Mechanical (HVAC) S List: ,S'[�,.
5. Mechanical (Fire S
Suppression) Total All Fees: S
�^ Check No. Check Amount: Cash Amount:
6.Total Protect Cost: S6 C.C/�`OD ❑Paid in Full O Outstanding Balance Due:
i o (PIKS
�b �
SECTIONS: CONSTRUCTION SERVICES '/, �/
5.1 Licensed Construction Supervisor(CSL) `j'�ol /p� % rC/ Z
WI�.y-yr 2` cI4 De License Number F p., un Uate
e of CSL-It der I.isl CSL"type(see below) (J
Dmri lion
U Unrestricted u to 35,000 Cu.Ft.
C9 Restricted IR2 FamilyDwellin
Si nalure a' �+ M Mason only
/ RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 tered Ho a Ie Improve eot Contractor(HIC)
Registration Number
f IIC Coom any Name or HIC Re Irani Name l
Dl
Esp' Lion Date
. ignamrc Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 ZSC(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 issuancgof 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
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
/�`r.Q SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
I 4 l /!mot]-QQj2jl�� r �J' /it/i;� _,as Owner or Authorized Agent hereby declare
that the statements Tnd information on the foregoing application are true and accurate,to the best of my knowledge and
attire of Owner or Authorized Agent D
(Sixncd under the pains and penalties of 'u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.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 healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SM EMs 1.LASSACHUSETTS
BUItDLNG DEPARTMENT
120 WASHINGTON STREIM Y°FLOGIt
TIE. (978) 743-9S95
FAX(978) 740`98"
ICI\BER"Y DRISCOLL TtOMAS ST.PMRRS
.UAYOR
DIItECTOa of rt el.tc ttaoPEaTr/at:Its,ac coWMstoNEA
Workers' Compensation Insurance Allldaeit: Builders/Contractors/ElectriclanslPlumbers
>nnllcant Informations Plesse Print Ledoht o�
Vatndltluane.rOrynusuon,ln�bv,dull' �/`�K< � `-` �� �`�tE� �/�Y9� .rJ5 CQ),
Address:
D�9'71
City/StatdZip: Phone 0: 9ZZ 7Y6
w Min empNyer'Check the appropriate boa: 1110.0
ype of project(required$
1. I am e,mploye:wick �. Q I ant a general eantnebor and I ❑Now caltattuetias
employees(full and/or part-time).• have hired 1lle sub�cwuraebars
2.Q 1 am a sale proprietor.w paatner- listed an rise attached shut t Q Remodeling
.hip and have no employee Thee sub-contraetor haw N. Q Demolition
worting for me in any capeciry, woken'comp.insunaea Q Building addition
(No warkera'comp insurance 3. Q We are•eerpantian and its
nvptiraL)
officers hew eowrtised their Electrical repsus or additions
1.Q 1 am a homeowner doing all wort right of exempion par MGL 11.Q PI mg repair or additions
c. 172.41(4).and we haw no
myself.(No worker'comp 12. Roof repeir
insurance required.) ► employee.LNo waken' I2.❑Otha
comp insurance require.)
-Aey appuaata net eberae hoe of men Aw fill.not The sorties below abowieg tbdr warble•tasrywtotYr pdiey infl rr uokiii.
'I onuworw wbo subs o ate aMdtra indieieg ilry are Join/to wait and dim hbe euwirk cmmw4s view ,hnil a new aMdwir indkaiee a.k.
<'.r.traton char rhea.big lwa.nW atladtwl an a.lditiotel riser sbswise Ito n.ee star w►sestteeaete ass cite wwbws'tong,pocky inasnoceft
/age an enepkyer that fr providinif workers'rompewmdns iwarrotaor fir my easp/ayee,a sehw hr Me,pNky a vdM xW
inforaradon,
Insurance Company Name: '41 C/
Pnlicy a or Self-init. Lie.A1: &e _ 7 2/W63 3 Expiration Date: —�
Job Sire Address: `�y Z ����/°fU City/Slatr/Zip: SS
Artack a copy of The workers'compens"Ma policy declaration pop(showing the policy number aN ospirotlon dtNe)6
F'ailuro to secure coverage as required under Section 25A of MGL e. 152 can led to the imposition of criminal penalties of
tine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDEA and a nob
of up to S230.00 a day ugainsf the violator. Ile adviuxl chats copy of this statement may be rurwa►ds d to the Office of
Inv.auguoiuns otlhe DIA for insuranco coverage veriticaliaL
/de hereby re y rho pins and pens/lies ojperjoey Met thw in/oratedow provided above is true,and.wr►ed
` " t Date:
D/ncie/use only. Do uof write in rhir arrsl,te be.a,,p/etd by rify or tuna alpt-idA �
I
City or ruwn: errmit/l.lcense tt_
(.suing Awhurily (circle unc):
I. Ituard of Ilraltb 2. nuilding Drparomene J. Cily/town Clark i. Flntrical 6npcctor S. Plumbing Impactor
6.01 her
Phan/e•
t.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1'.U: M111 ' Nly ,'It
5•\I Isl. %1.\K.\4 111 J I...1'� .
l'n:97t-7/i.•1}y! I°.tx:H767J,}'ItNh
Construction Debris Disposal AMdavit
(required fur all demolition and renovation work)
In accordance with the si.xth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building lacrmit p is issued with the condition that the debris resulting from
f this work shall he disposed of in properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
puma ul hauler)
I'he debris will be disposed of in :
(nameol facility)
addrcNN ur I':x ilityt
.Ignatwe Iwrmit+pplicaM
date