461 LORING AVE - BUILDING INSPECTION r
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The Commonwealth of Massachusetts
°tA, OF
Board of Building Regulations and Standards CITY M
�` Massachusetts State Building Code, 780 CMR S
�1 ReviseddMar Mar 2011
JA Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use O
Building Permit Number: DateAppli
V f
Building Official(Print Name) P Si ature Date
SECTION 1:SITE IN O ON
1.1 Property Address: 1.2 As rs M Parcel Numbers
Ave
1.1a Is this an accepteH street?yes no Map Number Parcel Number
13 Zoning Information: 1A Property Dimensions: ,
Zoning District. Proposed Use Lot Area(sq ft) 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 Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 OwnerrofRecord• dA_ v19 -Z
em,4�L.,'i AfKi�S 5kle�rl /"et (7
Name(Print) City,State,ZIP
Y(o l �t-inq AVF 7L/q-6 SZS—
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee: $ - Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: ���
5.Mechanical (Fire Su $ Total All Fees: $
Suppression)
�/� /� Check No. Check Amount: Cash Amount:
/ 6. Total Project Cost: $ W.OIJ ❑Paid in Full ❑ Outstanding Balance Due:
�►,�� � J ICJ FE'��
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder.
Lis[CSL Type(see below)
No. and Street Type. Description
U Unrestricted(Buildings u to 35,000 cu.Ft.
R Restricted 1&2 Family Dwellin
City/To",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 BUILDING 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 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
p By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con tai in this application is true and accurate to the best of my knowledge and understanding.
2/ ;?ol
PPr9tOwner'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
www.mass. ove /oca Information on the Construction Supervisor License can be found at www.mass.. ov/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 sm-E.m
PUBLIC PROPERTY
DEPARTOMENT
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HOMEOWNER LICLNSB EXE.%ffj0,V
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Home Owner Address 5rm e
Home Owner Tolepbone -74iq-pg 2
Pteson Mailing Addrm 7&TL,rns ffi e (••�
h@ current exemption of"Homeowner"wa@ extended to inchdo owner-occupied
dweUings of two Unit@ or 190 and to allover such homeowner to eagsg@ an individual for
hire who.dam not possess a Ueense�provided that the owner acts"supervisor.
DEFlNM0N OF HOMEOWNER
Person(s) who owns a parcel of Lod on which hdsh@ reside@ or intend@ to reside. on
which then is, or is intended to bq a one or two firmly dwelling; attached or detached
struetttrm accessory to such use and/or than structures, A person who construct@ more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building OQleial, on a fora 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 regulsdon&
The undenigned "homeowner'certifies that helshe understands the City of Salem
Buulding Department minimum inspection procedures and requirements and that he/she
Will comply with said procedures and uiremertm
HOMEOWNERS SIGNATURE -
.APPROVAL OF 91V/LDIYG CiSPECTOR
See other side far state code
CITY OF SAIL.M, 'LASSACHUSETTS
• BUILDIING DEPARTM&NT
120 WASHINGTON STREET, 3iO FLOOR
TEL (978) 745-9595
FAX(978) 740-98"
KiN BFRt RY DRISCOLL
MAYOR THt�tA OS ST.PmRRs
DIRECTOR OF PUBLIC PROPERTY/Buumj VG COMMSSIONER
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 o uler)
The debris will be disposed of in
��6�evrt I�ans7c�
(name of facility)
�avnp,XO
(address of facility)
Ht/
signature of permit applicant
(12
date
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