256 LORING AVE - BUILDING PERMIT APP t
The Commonwealth of Massachusetts l
Board of Building Regulations and$,fQ&ds i CITY OF
Massachusetts State Building Code;780 CMR SALEM
1�_A
' `` Revised Mar 2011
Building Permit Application To Construct,Repair,ReW&MV;6molish a
One-or Two-Family Dwelling
This Section For OfficiaVise Only
Building Permit Number: Date plied:'
fir,.✓ - 17 IS
Building Official(Print Name) _ Signature- - - Date'
SECTION:SITE INFORMATION
1.1 Proprty��ess��/N� ✓�. 1.2 Assessor�ap&Parcel No
e2
L l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area sq ) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information] 1.8 Sewage Disposal System:
/ Zone: _ Outside Flood Z$ne? —/
Public!1 Private❑ Check if yeses Municipal L�l On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of ecord:
Gr/A / P? 1CPe vc;il/ Sq 1P/y/ 92d
Name(Print) nCity,State,ZIP
2S6 /o/?i/f/GJ Gr t/� 72,= %r-,5S 6 �'i Pri ff e�l Odd P )/ /j oa•laM
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORR2(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 2:
`c�/h��l)e ?ice v P o,•t �-���.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only'
Labor and Materials ,
1.Building $�'oq/. G� 1. Building Permit Pee:$ Indicate how fee is Bete ed:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x__�_
3.Plumbing $ 2. Other Fees: $ - - _ i
4.Mechanical (HVAC) $ List: - W- y. rn
5.Mechanical (Five —
Suppression) $ -Total All Fees:$ - rq
Check No. Check Amount: Cash AmourN
6.Total Project Cost: $ �GUU, p� ❑Paid in Full ❑Outstapdin�Balance Due: 12
N
0Z SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date '
Name of CSL Holder
List CSL Type(see below)
A
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 to.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP 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 BU DING 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) Date
SECTION 76:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
w•ww.m&ss.sov/oca Information on the Construction Supervisor License can be found at www.m&ss. ov/dns
2. When substantial work is planned,provide the information below:
Total floor 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"
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