6 LOVETT ST - BUILDING INSPECTION The Commonwealth of Massachusetts
�- OF
Board of Building Regulations and Standards CITY M
h B C Massachusetts State Building ode, 730 Cb[R $dMar Revised iLlr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tivo-Family Dwelling
This Section.For Official Use Only
Building Permit Number: ` Date Applied>',
Building Official(Print Name) Signature Date,.
SECTION I: SITE INFORMATION
1.1 Property Address: L2 Assessors Map& Parcel Numbers
e �t
Lov +1
1.la 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 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:
Public ❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
" SECTION 2:, PROPERTY OWNERSHIPi
2, of Recor 11
YYACIs �1Gvrt �`P_, JA'\ C>\G 10
Name(Print) City,State,ZIP -
tA l yVrtt4 5
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK"(checkall that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Dzmolition ❑ Accessary Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
V—ev (>w< 2lC 5 4 l- Cvve eft Y�v
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Item Estimated Costs: Official Use Only. ,
Labor and Materials
I. Building L Building PermitFee. S Indicate how fee is determined:
❑ Standard City/town Application Fee
2. Electrical 5 i
.❑'Coral Ptolebt Cost ,(Item b)s multiplier x
3. Plumbing S 2. Other Fees: S �� 1
t. %lechanical (t[VAQ S List: h (� 1
5. \lechanical (Fire $
Sijp ression) Total All Fees: .>_
Check No. Check Amount: Cash Amount:
6 I,otal Project CosC S 3S(�� l (3 Paid in Fall ❑ Outstanding Balance Dtic-
SECTION 5: CONs'l-RUCTION SERVICES
5.1 Construction Supervisor License(CSL) 0k:z;�> (�7- \a-M
C>" S (-- S C,y _ License Number Expiration Date
Name of CSL l folder J
` � List CSL Type(sae below)
��4..✓t.J c 0 9 t7 ' U t
No. and Street Type tInsulation
� Description
U icted Buildin s u to 3i,000 cuIt.IMIA G�\°t 6e� a ed 1,�2 F:unil DwellinCity/Town, State, ZIP II RC Covcrin\VS and Sidin
nSF el Burning Appliances
'I1� �� 1 (�� a}^^` 11 �YS [ n1'ele hone Email address .1 .«^ D ion
5.2 Registered Home Improvement Contractor(IIIC) `"3 dt 0
9f,k �u"`\c-,\"� x'�'�"'�`'(v"h ��' IIIC Registration Number Expiration Date
I Il"orripany4NtiX or IIIC Registrant Name
`bb �^-^-t 12)
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 ..........Id 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
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this a Iication is true and c ur t to the best of my knowledge and understanding.
Print Owner s or Authnrized:\gent's Name(Elcctro 'c 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
(riot registered in the Honte Improvement Contractor(H[C) Program), will not have access to the arbitration
program or guaranty fund under A.G.L. c. I42A. Other important information on the HIC Program can be found at
w ww.ncusoovr'oca Information on the Construction Supervisor License can be found at www.mass.,lr3 w CIO
2. When substantial cork is planned,provide the information below:
Total floor area(sq. ft.)-_ (including garage, finished bascment/atticS, decks or porch)
Gros> living area(sq. 11.) _ _ Ilabitable room count
NinnberoFtircplaecs_-_ --- Number ofbedronms
Number of bathroottts Number of halt;baths ---- _
fcpe of heating systcut - _._.---_ ----- Number of decks/ porches —_--___-
1'�pe of cooling syaent___----------_--- Enclosed--_ - _- - -----Open _ ---
3. "Iotal PnOjcc[ 5yuarc 1"11,Hagc" inay be subctihitcd tau-'ful.il Ihojed Cott„
4
°" CITY OF Sm E,,I, NLkSSikCHUSETTS
BUILDING DEPARTNI NT
a to ?r 120 WASH04GTON STREET, 3"FLOOR
'r'� TFL (978) 745-9595
FA.xt(973) 140-9844
lU\InERL.HY DRlSCOLL
I
�1AYOR �tOiStAS ST.ptE.aRB
DIRECTOR OF PUBLIC PROPERTY/BUM.OL1G COMMISSIONER
Workers' Compensation Insurance Afffdaylt: Builders/Contractors/Electricians/Plumbers
Alirtlicant information Please Print Legibly
Name tausiivs&organi=atiamin�ivid`ual): �a"I S��-� ��1'G� t•^a � � ��-t^n 0c9e( t...�
Address:— _2 ill
City/Statl:Mp: �G 1 G^• . AAA o tsw Phone#: 9'1 ^l k1 uu
Are you an employer?Check the appropriate boss Type of project(required):
i. I am a employer with 4. 0 I am a general cantractot and 1 6. ❑Now construction
employees(flall and/or part-time).* have hired the sub-cantractors
2.❑ 1 am a sole proprietor or partner- listed on the attached.rheat.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 11. ❑ Demolition
working ter me in any capacity. workers'comp.Insurance. 9. Building addition
(No workers'comp. insurance S. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repair or additions
J.❑ Iran a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees.(No workers' IJ.❑Other
comp.insurance required.)
• -Any arpllcad awt chuks baa tl must also all out the scvtioo below showing chair warhas'ornpent uloo puncy intbrmaiat.
'I hwnuuwnam who sdmsit this atTdavit indicafne they aft doing all work and then him ouisideconnactes must submit a crow affidavit indicating suck
:Conimion that vitmit this box Mena onaahud an a llunol eha$showing the name of the sutt,•comrutars and their workers'ramp policy Information.
lain no eliplayer thaNs provfdiog workers'rompeusadan Insurance jar my employees Below la the policy and Job site
inform"don.
Insurance Company Name.* y-s 1 w i�Ao yt k _ ,.-v'v$�L C—cc Ca•
Policy 4 or Sclf•ins. Lic. e: Expiration Dote: 3—\ S — k
Job Site Address: a✓G 5 City/Slatc/Zip:
Attach a copy of the workers' corapensatlon policy declaration page(showing the policy number and expiration slate).
h'ailunt to secure coverage as required under Suction 25A et'NIGL c. 152 can lead to the imposition of criminal penalties of a
ring up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and aline
of up to$230.00 a day against the violator. Ile advfsed that a copy of this statement may bar forwarded to the Of lieu of
Investiguliunv of the DIA fur insurance coverage vurilieuliur
/do hereby rrrrljy ur r der pulps arrJ teuu/Ile jprr/u /rat the brjurmwlon provided above is true and correct
PhoncrJ:
_i D fc•iul use unl. Du not wtife in t/ds err to be cum hied b cif ur lawn n/Jklat// y a, P Y Y �
City nr'fuwn. Permit/I.Icense x
I.muing Auiliurity(circle one):
1, !hard of lieallh 2.Building Department .l.City/I'uwn Clerk J. Electrical luspector S. Plonihing lnapeclor
� 6.Other
Conlact 1'ennn:. ... ___. _.. Phone II:
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CITY OF Sc L,EM2 NWSACHUSETTS
BL'tLDL%G DEPARTMENT
fi r 120 WASNLYGTON STREET, 3w FLOOR
TEL (978) 745-9595
F
K1JiBFRI.EY DRISCOLL .A-x(978) 740-9846
NLWOR T osw ST.PIERRB
DIRECTOR OF PI:BLIC PROPERTY/Bt:M.DLYG C01Wt55lONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of tb1GL 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:
1�J C)V J.,r- Cc -t-,_.
(name of hauler)
'['he debris will be disposed of in
(name of facility)
SQI viva
(address of racility)--
signature ofpermit applicant
II