456 LORING AVE - BUILDING INSPECTION f
A The Commonwealth of Massachusetts INSPECTIONAL SERNJU&
it Board of Building Regulations and Standards SAL&ECM
Massachusetts State Building Code, 780 CMR 1015 APR 14 A"'ff-d y 4 '011
(-- Building Permit Application To Construct, Repair, Renovate Or Demolish a tS 4
CIO One-or Tivo-Fmnily Dwelling
This Section For Official Us#Onl
Building Permit Number: Date Appiied:
Building ORiciul(Print Name). Signature Date
SECTION 1:SITE INFORMATION`
L1 Proper�y Address:, 1.2 Assessor Nap&Parcel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Euningstrict Proposed Use Lot Area(sq It) Frontage(It)
dingSetbacks(R)
Front Yard SideYards Rear Yard
ed 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? Municipal� On site disposal system ClPublic 6 Private❑ Check if es®/— p
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
s)10091001?,� �Av� sG
iT�m—e(Print) City,Slate,ZIP
�/S`6 lariirs /�vE 76�`B6y-98/2 �/o7,odoo
✓/1.7R.rA�i��a P/Z�
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied 21 Repairs(s) tyl Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
RP.��ILP £X/S11h r E44 r/c 'r dPPA A,/A4 'C /7EIy
SECTION 4:ESTIMATED CONSTRUCTION COSTS
11C Estimated Costs:ni Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S 0 Total Project Cose(Item 6)x multiplier x
3. Plumbing S 2V Qlher Fees: S
4.Mechanical (tIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Su ression)
�. Check No._Check Amount: Cash Amount:_
6. 'rutai Project Cost: S �� 000. 0 Paid in Full 11 Outstanding Balance Due:
SECTION5: CONSTRUCfIONSERVICES
5.1 Construction Supervisor License(CSL)
i License Number Expiration Date
Name of CSL Hulder List CSL'rype(see below)
No.;mJ StreetType Description .
U I Unrestricted(Buildings tip to 35,000 cu. It.
MD
Restricted 1&2 FamilyDwelling
Cityfrown,State,ZIP Maso
C Roolin Covcrin
S 1Viadmv and Sidin
S01id Fuel Doming Appliances
Insulation
Telephone Email address Demolition
5.2 Registered Home Improvement Contractor(NIC)
HIC Registration Number Expiration Date
IIIC Company Name or IIIC Registrant Name
No.and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.§25.C(6)y.
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Islivance of the building permit.
Signed Affidavit Attached? Yes ..........13 No...........❑
SECTION 7a:OWNER AUTHORIZATIOrK TO BE.COMPLETED WHEN: .','.
OWNER'S AGENT OR CONTRACTORAPPLIE3 FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,)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) Dale
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 Loot have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program can be found at
%cwvv mass.cov:'oca Information on the Construction Supervisor License can be found at AAA111as� .
2. When substantial work is planned,provide the information below:
'rota) fluor area(sq. ft.) 'a •(including garage, finished basementlattics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating syston Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM, MASSACI-IUSETTS
BUILDING DEPARTMENT
�iiy ✓,s 120 WASHINGTON STREET,3"°FLOOR
F
��""re4sv TEL. (978) 745-9595
FAX(978)740-9846
KINMERLEY DRISCOLL
MAYOR TrIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COM&IISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
'/Z!2 s Dater ivy r /
Job Location ?
Home Owner Address—
Present Mailing Address
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 that 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 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
f
CITY OF SALEM, IVMASSAaiuSE M
i BUILDING DEPARTMENT
120WASHINGTONSTREET,3RDJJ pR
nL.(978)745-9595
KIMBERLEYDRISODLL FAX(978)740-9846
MAYOR THomm ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUII.DING ODAWSSIOMR
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit#t is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
ei 1571T
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
I