17 LOVETT ST - BUILDING INSPECTION (3) CC� St 1 �ZSa"
' The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
U / Massachusetts State Building Code, 780 CMR Revised Mor 2011
,
l Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For DIN 'aI Use Onl
Building Permit Number: Date.Applied:.
e S ZS
ame).
DuiiJingOlTiciul(PrintN Signature
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SECT[ON 1:SITE INFORMATION. �
1.1 Property Address: 17 LOVETT ST 1.2 Assessors Map&Parcel Numbers '< rn
GA(FM . MA ^� �m
1.1 a Is this an accepted street9 yes_ no Map Number Parcel Number r—m
N�
1.3 'toning Information: 1.4 Property Dimensions: rn
Tuning District Proposed Use Lot Area(sq R) Frontage(11) n
rn
1.5 Building Setbacks(R) N
Front Yard Side Yards Rear Yard
RcquircJ - Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.S Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal E3 On site disposal system ❑
Public❑ Private❑ Check if es0
SECTION2: PROPERTY OWNERSHIP!`
2.1 Owner'of Record:
aRT- "60- 1i —aNZ
I�t1me(Print) City,State,ZIP ,
sHMC 97 q3y- 3 h1433oe ao. o�-•
Nu.mrd Stn:ct Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied O 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition 0 Accessory Bldg.O Number of Units_ I Other 0 Specify:
Brief Description of Proposed Work-:^n n °r WALL RE-MOVAL WL!l
/NST79Lt.C7= OF S'HDWF?�L S'Tx)iC /A) NAxE_BH-rN
v ON 21ll) f-L&Ve2
SECTION a:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
0 Standard City/Town Application Fee
2. Electrical S 0 Total Project Costs(Item 6)x multiplier x
3. Plumbing $ 2`?Qther Fees: $
4. Mechanical (FIVAC) S List:
5.Mechanical (Fire S Total All Fees:S
Su ressiun)
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: 'S 3500 . OO ❑Paid in Full ❑Outstanding Balance Due:
T jAeA GP'L.C, 5 (e.. tJ lk\r 1 ,
SECTION 5: CONsTRUCfION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Dale
Name of CSL Holder
List CSL'fype(see below)
No.and Street Type - Description .
U Unrestricted(Buildings up to 35,000 cu. 11.)
R Restricted U2 Family Dwelling
City/rown,State,ZIP M Masonry
RC Rooting 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
IIIC Company Name or HIC Registrant Name
No.and Street Email address
-City./Town, State ZIP Tele hone
SECTION&WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.151¢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 Isivance of the building permit.
Signed Affidavit Attached? Yes..........O No...........O
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN
OWN ER'S AGENT OR CONTRACTOR APPLIES BUILDING PERIIHT'
I,as Owner of the subject property,hereby authorize
t9 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:OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my name below,) 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.
5 22 16
Print m ter's or Authorized Agent's Name(Electronic Signa ) 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 M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.ntass.eov'oca Information on the Construction Supervisor License can be found at www.mas� _
2. When substantial work is planned,provide the information below:
'total Moor 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/porehcs
'type ofcooling system Enclosed Open
1. "Total Project Square Footage may be substituted fur"Total Project Cost"
QTY OF SALEM, MASSACHUSETTS
t ' I BUILDING DEPARTMENT
120 WASHINGTON STREET,YD FLOOR
s
TEL. (978) 745-9595
FAX(978) 740-9846
KIb, BERLEY DRISCOLL
MAYOR THOMA$STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date .3 /Job Location l7 Lou&TT s - sot-E-M, NA- 01970
70
Home Owner Address—
Present Mailing Address
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 that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) 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 form 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE (o awn Q._.hwh
APPROVAL OF BUILDING INSPECTOR
QTY OF SALEK MASSAaiu5Em
f } BuiDINGDEPARTMENT
120 WASmNGTON STREET,31D ROOR
7i L(978)745-9595
FAX(978)740-9846
KIlvIBERLEYDRISOOLL
MAYOR THoMAs ST.PIERRE
DIRECTOR OF PUBLICPROFERTY/BUIIAING OOMUSSIOMR
Construction Debris Disposal Affidavit
(required for all demolition and renovation work j
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL 00, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler) eypj ZD,
The debris will be disposed of in:
(name of facility)
(address of facility)
n
Signature of applican
ate