461 LORING AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
1 ; Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEN
Revised iUar
L/nr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This Section For Off'is Use Only ,
Building Permit Number:
' pp
` ' , ,�,.�.,� Lai, Q• Gi
wilding Official(Print Name). Date
SECTION I:SITE INF ATION
1.1 Pro erty AJdress: 1.2 Assessors Map& Parcel Numbers
L I 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 tl) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes0
SECTION 2: PROPERTY OWNERSHIP``
2.1 caner of Record•
0,, L �11c�1 S le�n , M� 0070
\/ me(Print) City,State,ZIP
LJ&J 4s - it i`Fz,- ?tiy-O825-
No.andNo.and S� Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(cheek all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) Cl I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':&de,? X2 41-�- R e•L d-61u1 K
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) -
1. Building S I. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ ❑Standard City/TownApplication Fee
❑Total Project Cosh(Item 6)x multiplier- x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Nfechanical (Fire $
�61
ression) Total All Fees:S
J ,20/,, �� Check No. Check Amount: Cash Amount:
otai Project Cost: S -7 V ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Bolder
List CSL"type(see below)
No.and Street Type, Description
U Unrestricted(Buildings Lip to 35,000 cu. 11.)
R Restricted 1&2 Family Dwelling
City/fown,State,ZIP M Nlasonry
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 BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
tq 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: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 applicattiilon is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
(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 not have access to the arbitration
program or guaranty fund under bLG.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eos;'oea Information on the Construction Supervisor License can be found at www.mass.sov/dos
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"
CITY OF SA .F-Nl. NLksSACHUSETTS
BLIIDIING DEPARTMIRNT
• I+• 120 W.NsHLNGTON STREET, 3110 FLOOR
$� TEL. (978) 745-9595
FAA.(978) 740-9846
KI%{BFRI F.Y DRISCOLL
MAYOR Tmo.%As ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BC1LDNG COMMISSIONER
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 c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(.nnaame�of�facility)
�aun�J.SCo I/ f`t-a.
(address of facility)
signature of PP
permit applicant
P
date
Icbrisalf.dux
CITY OF S.ULEN(
PUBLIC PROPERTY
DEPARTN ENT
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HOMEOWNER LICENSS E.XX.NMj0►V
Please "t
Oats ZI l3
Home Owner Address y&( Lc,,- k fizz
HomeOwoerTelophone h7ss-7v`y v8
Present Mailing Addrw qLg Lcv�A,� mive-
Tao current tsstempdos of"Homeowners"was eatended to inchadet owner occupied
dwellings of two Unit@ Or less and to allow reach homeowners to engage as individual for
him who doe not possess a IleensIN provided that the owner acts as supervisor.
DERNMON 0I HOMEOWNER
Pawn(s) *be owns a parcel of Lad an which WsM rrsidae or intends to rtedde, an
which than is, or Is Intended to be4 a one or two hazily dwelling, attached or detached
atructUrn accessory to such use and/or farm Micturee, A pangs who conswxu more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"sW submit to the Building Weill,an a form acceptable to the Building
Oircial, that he/she be responsible for all such work parformad under the Saailding
Permit,
The undersigned "homeownee assumes responsibility for complimme with the Stan
Building Coda and other applicable bylaws and reguladons.
no undenigtred "homeowner certifies that he/she undentands the City of Salem
Building 0epartment minimum inVadon procedures and requirements and that hdsho
,vill comply with said procedures requireamnen
HO1,lEOW`VERS SIG:IA I
IY
SPkPPROVAL OF BUILDG OiECTOR
See other side far state cods