465 LORING AVE - BUILDING INSPECTION !i The Conimonwealth of Massachusetts
�\ Board of Building Regulations and Standards FOR
Massachusetts State I3uildine Code. 780 C'MR. 7"' edition I,til:
Building Peimil Application To Construct. Repair. RetloNale Or Demolish a Krt isol.hu n i,i
One- or Tit o-F'umily Duelling 1, 011S
This Section For Official Use Only —
Building Permit Nut er: Date Applied: r7
--------
Building Conunissioner Inspector tit Buildings Date
SECTION l: SITE INFORMATION _.
LI Property Address: 1.2 Assessors Map & Parcel Numbers
I.la Is this an accepted sit eet! yes___ no.___ Map Nunth—r Parcel Number
1.3 Zoning Information: ------ 1.4 Property Dimensions:
Zoning District Proposed Use---- Lot Area(sy it) ---�— Frontage (it)
1.5 Building Setbacks (ft)
Front Yard. Side Yards Rear Yard
Required Provided Required Provided Required ProviJrd
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 s ,Icm ❑
Public ❑ Private❑ Check if yes❑ p I royay
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
_ E7)i,,AQ ) rvoLA H {/6s Low. A✓c
Nam (Print) Address for Service:
_ I�Ialae� 9-78 SS'/ o4s4 -
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairsls) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify: —
Brief Description of Proposed Work': 11,i- .—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 00b 1. Building Permit Fee: $ Indicate how fee is detnmuried:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $
. Other Fees: $
4. Mechanical (HVAC) $ List
i. Mechanical (Fire $ Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount___
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:__-___
SECTION 5: CONSTRUCTION SERVICES , -
5.1 Licensed Construction Supervisor(CSL)
License Number f.cpiration Date
Nantc of CSI-- Ilaldcr R C-
List C'SL Type (see hclow) _
lddress -I'Ype Dcscri Lion
L L'nrestneted (tip to 3>.000 Cu. R.)
R Restricted-)&'_ Famil D)selline
Somamre M .Masonry Only
RC Residential Rootinc C'oserme
'fclephone \1'S Residential \Vlndo\e .lnd
SF Rcstdenu:d ..Sohd Fuel Buomte A >>liancc In>Lil l.un ni_�
U Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Nmne or HIC Registrant Name Registration Number
Address
t ----__.
--E.cpo utiun Date
Signature P:icph,)ne
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.
l
Signed Affidavit Attached'? Yes .......... ❑ No ....... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
(, 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.
gnature of Owner Date --
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, _ �TSa� a 2�, IPA S`NCU�!4-t , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name���� /
S -o?a•y 8
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 01IC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Pro.-ram and
Construction Supervisor Licensing (CSL) can be found in 730 C'MR Regulations 110.116 and I IO.RS, respectively.
When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including garage, finished basement/attics,decks or porcht
Gross living area ISq. Ft.) Habitable room count _
Number of fireplaces _ Number of hedruums _
Number of bathrooms Number of half/bath.
Type of he:uing 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 S kLEIM
PUBLIC PROPERTY
DEPARTMENT
ivaa�tttbr -
130 WA9uNG70N SIVEiT•%A1 EM,SrASLU34LshM 01970
TEL 97&74S-9S95 0 FAX.97L740.964
HOMEOWNER LICENSE EXEIMMON
Please Print
Date
JobVlocation ��J �D22hg AJC
Home Owner Address 4(oS L.ea , ,4 Aye.
Home Owner
�Telephone 9n ssv ogss
Present Mailing Address SAMG i
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 license,provided that the owner acts as supervisor.
DEFINPPION OF HOMEOWNER
Persons) 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 fort 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
y{`� '� :�;;T CITY OF SALEM
„ ,
i PUBLIC PROPRERTY
~' • DEPARTMENT
.I`.11: F:I I.': 9U" , 'i 1
M "'I 12G 'T
Iiq 91V-45-9;95
Construction Debris Disposal Affidavit
(nrluired Iitr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CIv1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit H is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
(name of hauler)
file debris will be disposed of in
(name ul taclhty)
r .4
(address of facility)
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