17 LOVETT ST - BUILDING INSPECTION (6) ^ nt- r
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[— The Commonwealth of MassaINW113 T IONA L SERVICE CITY OF
Board of Building Regulations and Standards SALEM
/ Massachusetts State Building Code, Nor 2011
1��°���3 3 A & 0l Revised,
I Building Permit Application To Construct, Repair, Renovate Or Demolish a
U I One-or Two-Family Divelling
This Section For Offs ` Use Only
Building Permit Number: 1.Dat Applied:
Building Official(Print Name). - Signature•
SECTION 1:SITE INFORMATION'
I.I Property Address: 1.2 Assessors Nlap dt Parcel Numbers
l 7 Love++ Sf
I.I a Is this an accelpted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zunin-District Proposed Use Lot Area(sq R) Frontage(It)
LS Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§Sd) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesE3
SECTION2: PROPERTY OWNERSHIP!`
2.1 Ownert of Record:
,Ayfhr,�— N rl�'hv Sct/vm MA 6IR70
ienc(Print) City,State,ZIP
'JC\ 17 Love-4-- S 976-y3N-18g3 S Lar � �uhoo•com
No.and Street Telephone C•mail Addnsg
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
k;e n reno �neW n&boeM 14bhbja�OltanreS reloralt err �
SECTION a:ESTIA(ATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ $000 I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S z000
❑Total Project Coll'(Item 6)x multiplier //(x
3. Plumbing S 500 PPtherFees: S
d. Mechanical (tIVAC) S List,
5. Mechanical (Fire S Total All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:
G.Tutal Project Cost: S !O/Sod ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES {
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
No. and Street Type - - Description
UI Unrestricted(Buildings tip to 35,000 cu. It.
R I Restricted 1&2 Family Dwelling
City/Town,Slate,ZIP M I Masonry
RC I Rooting Covering
WS I 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 IIIC Registrant Name
No.and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.1 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[nuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION,TO BE.COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIE3 FOR BUILDING.PERMIT`
1,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:OWNERI 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.
k�a ,en .? i0r'a oLe-ram y-2 -l5
\ 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 no have access to the arbitration
program or guaranty fund under INI.G.L.c. 142A. Other important information on the HIC Program can be found at
www m:us.gav'oea Information on the Construction Supervisor License can be found at w �v:!dos .
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. ft.) 'a (including garage, finished basementlaltics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Numbcr 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 1'or"rota) Project Cost"
CITY OF SALEA MASSACHUSETTS
BIAIAAJG DEPAR7MENT
120 WASIMCTOONSUEET,3xDR.oOR
ZkL(978)745-9595
FAX(978)740-9846
RIIvISERLEYDRISCOI.L
MAYOR TIKWAS STAMM
DIRECroR of PLmucrRorERTy/BIAIDm oclwsslomR
Construction Debris Disposa/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 c4O, S 54; Building Permit f< 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:
PeorSO n l u(nOs kr Co . Q j Pe Id , MA
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
` QTY OF SALEM, MASSACHUSEM
t BUILDTNG DEPARTMENT`
120 WASHNGTON STREET,3R FLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THomAS STTIERRE
DIRECTOR OF PLBLICPROPERTY/BUILDING COMI&ffSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 9-,2-/5 \
Job Location 1 -7 Love V . SGL/eml MA
Home Owner Address 'S amz
Present Mailing Address S Q M_X_
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 KQ/IQJ� �/ . l I - i7/ 46ur Nerlih
APPROVAL OF BUILDING INSPECTOR
7 )