15 LOVETT ST - BUILDING INSPECTION The Commonwealth of Massachusetts
n OF
Board of Building Regulations and Standards CITY SALE M
\ Massachusetts State Building Code,780 CMR
I Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
(� One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D p ed:
ire: . 1� Lu I L—x� -
Budding Official(Print Name) St Date
SECTION 1:SITE I RMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Lin Is this an accepted street?yes no Map Number Parcel Number -
1.3 Zoning Information: IA 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 yes
SECTION 2: PROPERTY OWNERSHIP' J�,{ /t �^2.1 tO�vwnerr of R or r-e �OY�/ S 1�/�(/� 1 "��`-r
Name' (prird) l City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIIPlTION OF PROPOSED WORK2(check all that apply)al New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: cJ
124 4
v
SEC TON 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building - $ -- (7Zj 1. Building Permit Fee: $ Indicate how fee is determined:
/ ❑ Standard City/Town Application Fee
2.Electrical $ C.� ❑Total Project Cost"(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ O Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ � ��� ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructi Supervise License(CSL)
S07 A,4A b License Number Expiration Date
Name of CSL Ho er
o /O� 1^� n . . �,.]„� List CSL Type(see below)
No.and Stree {,v�'f'VO"l! 1 Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
A-1 Irt' C./v l R Restricted 1&2 Family Dwelling
City/Town,State,ZIP ll II M Masonry
RC Roofing Covering
WS Window and Siding
/� SF Solid Fuel Burning Appliances
/`� C&F—A(.OWAJ I Insulation
1 Telephone - - Email address D Demolition
5 2 Registered)Home Impp//rro,ve�ment Contractor(HIC)
HIC Registration Number Expiration Date
BIC Corypany Name r IC R�strant Name
No.and Street ll`�' 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 J Qr I n a I I 1 o /
to act on my behalf,in all matters relative to work authorized by this building permit application.
i ate� \\
Print Owner's Name(Electronic Signatu
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 application is true and accurate to the best of my knowledge and understanding.
Print Owner'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.gov/oca Information on the Construction Supervisor License can be found at www.rnass.gov/dVs
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"
i CITY OF S.UX.%1, %LA SSACHUSET rS
• BUIIDIING DEPARTM&NT
• 120 WASHINGTON STREET,3w FLOOR
�tedj TEL, (978) 745-9595
Fkx()7R)74n-OR 6
K.TN tFRt EY DRISCOL
Nf THOMAS ST.PIF1tRE
DIRECTOR OF PUBLIC PROPERTY/BCILDOIG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrictarts/Ptumbers
d,rinlicant Information Please Print Leeibly
Name(Businc sorganintiorvindivviiduual):: 11�;70
Address: �'d--
City/State/Zip: 2 Ugh ne q: `1� f� 6 ' 1 b Q
Are you an employer?Check the appropriate boa: Type of project(required):
1.Ej 1 am a employer with 0 4. 1 am a general contractor and 1 6. 0 New construction
employees(fall and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.2 7.9Remodeling
ship and have no employees These sub-contractors have 8.'❑\Demolition
working for me in any capacity, workers'comp.insurance. 9, 0 Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its -
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.)No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' ME]Other
comp.insurance required.)
-Any apPac m1 that drake boa al muss also rill out the section below showing their workers'compensation policy infutmatioa
I Iomeownen who submit this affidavit indicating lhuy are doing all work and dim hire outside commotm must submit a now aaSdavit indicating saA
:c.m aston that check this box must anached an additional sheet showing the name of the subeonuactors and their woken'comp.policy information.
I um an employer that is providing workers'compensation insurance form employees. elow Is the policy and fob site
information, / C7 � �F / �^ ej�
Insurance Company Name. 7 6 QQQ��I �GGJ�, ` 1t/
Policy A or Sci-ins.Lie.A: • L/ Z'�� L 0 C— Expiration Date:
Job Site Address: Z. l� �/Y� SA��— M-City/Staterzip:
Attach a copy of the workers'compensation policy declaration page(showing the polity number and expiration dateh
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigation_of the DIA for insurance coverage verification.
I do hereby ce�1�and th ns and pens that the information provided above Is true and correct,
Si enao are:
Phone
Offciol use wdy. Do not write in this area,to be completed by.city or town official
City or Town: Permit(License q
Issuing Authority(circle one):
L Board of lleaith 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone It:
CITY OF S.U.&M, TN'LkSSACHUSETrS
• BLII,DIING DEPARTMENT
120 WASHLNGTON STREET, 3" FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI\fgERI EY DItISCOI L
MAYORTHOSL\S ST.PIFRRE
DIRECTOR OF PUBLIC PROPERTY/BU HMLNG CONM ISSIONER
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 : n
( ame of facility)
(address of facility) -�
nature of permit applicant
� ck
date
dcbri.lffdm
Massachusetts -Department of Public Safety
• Board of Building Regulations and Standards
Construction Supervisor
License: CS-091191
JOHN AMBROSE '' " �•
402 MERRIMACST43�
MEN BURYPORT MA 0y19�/0
V `
- 11 W Expiration
Commissioner 04/27/2014
Of(iee ofZ`oasa��er Wain �sio-ess Regu�la6 .
HOME IMPROVEMENT CONTRACTOR Type:
Rogistration:,�.138151
-. - - Expiration: 22512013 - - Private Corpo ':i;
d HORSE BUILDING AND REMODELING INC - -
t �
e� JOHN AMBROSEF.����1✓
-403 MERRIMAC -�—
# NEWBURYPORT,MA 01950�� Undersecretary
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Subcontractor's List with Worker's Compensation
Any Season Painting
Kern Electric