456 LORING AVE - BUILDING INSPECTION (2) - ----
�, l'he C'onunonwealth of Mussachuscus
Board of Building Regulations and Standards Cl VY OF
1 I l Massachusetts State Building Code. 780 C NIR SALLr%I
I` Building Permit Application To Construct, Repair, Renovate Or Den olish a
One-or Two4a nill Du dlfin,q
This Section For Official Use OnlyJ
Building Permit Number: ate Applie
1,14-6ZW'-L3 /
Building 0117cial(Print Name) Signature Da1L
SECTION 1: SITE INFORIIIATION
L I Property Address: 1.2 Assessors Map& Parcel Numbers
I.la Is this an acce ted street? es no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
7mthlg District Propow:d Uw: Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.JU, §14) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposul system O
Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ow� S rd:
Name(Print)
FpCuy.Slutc.l.IP ,yam
f LOri� c �Uli 7f l fx-pl'901z— �j i�////chFE 19� '
Nu.anJ Slroel Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building D Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ III Accessory Bldg.❑ Number of Units_ Other ❑ Spccity:
Brief Description of Proposed Work-:
SECTION 4: ESTBIATED CONSTRUCTION COSTS
Item t
r
Official Use Only
Y
I. building Building Permit Fee: S Indicate how fee is determined:
'. l:'latrical Standard City?own Application Feeotal Project Cost'(Item 6)x multiplier —_.x _ __�. I'luud+ing Other Fees: SII\'.\ t:lFire - --- ��-.�. .l .\II Fees: S n. Total Project Cuck Nu. _-_--Check Anwunt: C,uh \mount:aid in Full 0 Outstanding BuLmee Due:
SEC110N 5: CONSI-Itlic.'rION SERVICES
5.1 Construction Supen is or I.ice nse(C S I.)
I icense Number 1:\piratioo Date
Nallic oI*(SL I lolder 't('SI. IMW Isce
I)PC Description
Sircct I I I inrestricted(Budd;....s'i*h to 15.000 Va. It.)
R Re.,tricted l&2 Famal 17111,11i-io
Mason
RC Roolin Coverin
A'S Window and Sidill
SF Solid Fuel Burning Appliances
la'a"'tion
elviihont: —Finail addresi D Demolition
5.2 Registered Home Improvement Contritclor(HIC)
I 11C Registration Number F\piralioo Duce
I IIC Compan) Name or I 11C Registrant Name
No. mid Street Email address
City/Town,State.ZIP relcithone
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 Afflclavit Attached? Yes .......... C No...........0
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.
Print Owicr's Naine(Electronic Signature) Date
SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION
-By entering my name below, I hereby attest under the pains and penalties of perjury that all of the inrormatiun
contained in this 3pplication is true and accurate to the best of my knowledge and understanding.
Print Owner's Signatoru) Date
NOTES:
I.7�\n Owner who obtains a=building permit to do his,her own work,or an owner who hires an unregistered contraour
e permit
(nut registered in the Home Improvement Contractor(HIC) Program),will 1U) have access to the arbitration
IS I u
ci.r a a d der\I G L - 1 4
program or guaranty tund under.M.G.L. c. 142.A.other important information on the HIC Program can be found at
nation on the Construction
�;O% I fill'brination on theConstruction Supervisor License can be found at
"I
2, \\hen substantial lurk is planned, provide the information below:
c
row floor area(iq, ft.) I including garage, finished basement attics,decks or porch?
Gross li%itigarea(scl. 0.) Habitable room count
11 \tanber of firelfla,:es Number of bedrooms
Num her ot'hathroonis
1%kinihcrofdecks porches
l"inclosed
he suhstittacd for l'olal Project Cost"
CITY OF S.UY. NI
PUBLIC PROPERTY
DEPARTMENT
u auusv^•�.•�
wrae t 3o WAMMCWW!Mean••sw.la NUMOK7em stye
nr_+ s-tu-ss"•F%x 978.740,96+e
HOMEOWNER LICE.YSE EXEMPTION
rise"grim
Dam I—
It
20/�
lob Location
Home owner Address Zogr C
Home Owner Telephone_ 7 8/— 6Y 9 F/Z
preseot Mailing Address ,el�,C
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 lice nso provided that the owner acts=supervisor.
DEFINMON OF HOMEOWNER
Persons)who owns a parcel of land on which be/she resides or intends to reside, on
whicb there is. or is intended to bs6 a one or two family dw@Uin& attached or detached.
euuctures accessory to such uss and/or farm structures. A person who constructs more
than one home in a two year period shag not be considered a homeowner. Such
aumeowna"shall submit to the Building Ot®ci4 on a form acceptable to the Building
Official, that he/she be responsible for all such wort 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.
HOMEOWNERSSiGNATL'RE -
.APPROVAL OF BUILDNG NSPECTOR
See other side Cor state code
CITY OF S,VZNI, >. tSS'kCHL:SETTS
"fa� JLMDLNG DEP.1A-n Lip
I_'V'V'kSNNGTON STREIrr, V*FZOOIt
rHL (973) 741.9591
KIMBERLfiY DR)SCOLL FVt(978) 74Q984
,titAY01< 7 kc.ws ST Pmxxx
DtnaCTCE OF PL SUC PROPER7Y/gC MnNC CC)JL%11S3lOV Elf
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with
ri
Deb the sixth edition of the State Building Code, 780 CM
R section I I I.1
s, and the provisions of MOL a 40, 9 J4;
Building Permit a 1 is issued with the condition that the dcbria resulting from
1 11, S I JOA.work shall be disposed of in properly licemed waste disposal facility as deRncd by,blCL c
The debris will be tr4n3portcd by:(name or'Aauler)
The debris will be disposed Orin :
4�/®..
(n�mf of facility)
s.L_�la.SC ell
(+ddreu or anl,iy)
�'dn+nuaofpermit + —
PPIc+nt
IJfp
r a/