17 LOVETT ST - BUILDING INSPECTION (7) -1,
The Commonwealth of Massachusetts
i Board of Building Regulations and Standards CITY OF
Ip( Massachusetts State Building Code,730 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
[his Section FbrOfficial Usa Onl
Building Permit Number: . Date Ap led '
Building Official(Print Name) Date
$tgnatttc /
SECTION I:SITE INFORNLATION
1.1 Property Address: /7 Lvve H- St- 1.2 Assessors Mip&Parcel Numbers
1.l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: L4 Property Dimensions:
Proposed Use Lot Area(sq ft) Frontage(it)Zoning-District
1.4 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided '
1.6 Water upply:(MG1 c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage/Disposal System:
Public Private❑ Zone: _ Outside Flood Zone?Check ifes❑ Municipal t9 On site disposal system ❑
3ECTIONZq PROPERTY'OWNERSH7Pi
2.1 Ownert o Record:
Ar,+-f,ur kierGhV Salelit W 01170
Name(Print) City,State,ZIP ,
1-7 LoVO - .Sf 7 -q3 ` 43
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OE PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building❑ i Owner-Occupied Cl Repairs(s) ❑ I Alteration(s) ❑ Addition 17(
Demolidun ❑ Accessory Bldg. Number of Units Othzr ❑ Specify:
Brief Description of Proposed Work': �[ c(
f. ,3 .i l r w 1
A' tt �a - s4tiO You 1 Sr
SECTION 4: ESTUNIATED CONSTRUCTION COSTS-
Item Estimated Costs: OffIcial Use Only,,..
Labor and Materials )°
1. Building S L Building Permit Fee.TIT indicate how fee is determined:
2. flectrical S ❑Standard..CityCI own,Application Fee,
❑'rotal Project Cost](Item.6)xmultiplier
x
1. Plumbing S 7. Other Fees:*S
1. ,Mechanical (11VAC) S List: _
. ,Meeh.utical (Fire S ✓
�iiP cs=run) _ 1•01a1 All Fees:S_
Chock No. Check Anwuut: Ca uwunt:.sh A
n I'uCtl I'rnject twat: $ �' SQQ QL) ---'
f ❑ P.ti,l in Pall ❑Outstanding Ilnlnnee Uud:
^J
sm*rION 5: CO;Vs'rRUCI'ION SERVICES
5A Construction Supervisor License(COL) —
License Number Expiration Data
Name of CSL I folder List CSL'fype(see below)
Type Description
No.and Street U Unrestricted Buildin s u to 35,000 cu. tt.
R Restricted 13e2 Famil Dwellin
-----------------
Citylrown,State,ZIP ?V \lasonr
RC Rootin Covcrin
WS Window and Sidin
rj7l—
Iuel Burning Appliances
on
Ible hone Email uJJress tion
5.2 Registered Home Improvement Contractor(HIC)
ation Number Expiration Date
I IC Company Name or II IC Regisunnt Name
No.and Street Email address
City/Town, State,'LIP Tale hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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 ..........O No Cl
SECTION 7a:OWNER AUTHORIZATION TO DE COIYIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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 None(Electronic Signature) Mate
SECTION 7b: OWNER/ 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 I and accurate to the best of my knowledge and understanding.ii
' / -
l'rint Owner's or.\utlw ed:\;tnt's N.une(Electronic Signature) Data
NOTES:
I, r\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program),will uo have access to the arbitration
program or guaranty rued under M.O.L. c. 142A. Other important information on the HIC Program can be found at
www nru+.tov%oca Information on the Construction Supervisor License can be found at wnew.uciss. �IL'+
2 When substantial work is planned,provide the information below:
rot:d floor area Oki. It.) —(including gangs, tinislied hascmentlattics,decks or purch)
t iro>; living area(sq. it _— Ifabitable room count _
Number of fireplace;...------_— `lumber of bedrooms -
------
Vomberorbadirnums _-,— `itiiberoflialtbaths ..- - --------.
f'.pC of lwming iy:leni Number or+ cc .,'rorc rcs -_.-. ..-_ .--__--
I\peofeanling iy'ICni Enclosed Tcn
I lord I'r,gart Oyu irC Foot.l„e.' may he m1l;t1111t:d h'r r„r.il I'rnjcil Coo, - --
CITY OF S.U-&Ni
PUBLIC PROPERTY
DEPARTMENT
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HOsLMEOlONER LICLNSS EAIB.Mnj0V
Pkrase lriet
Date
lob Laeadcn /7 Lo y -I+ S-L - Sal e w'�,a luyl
Home Owner Address
Home Owoar Telephatse
Praw Mailing Add ese
The current esempdon of"Homeownerer was extended to include owner-oeeupied
dwellings of Me Unit$or leas and to 311OW such homeowoe:s to emgsge an individual for
hire who does not possess a Heense�provided that the owner seta as supwASW.
DE INMON Of HOMEOWNER
Penon(s) who owns a passel of l nd on which he/she resides or intends to reside, an
which there it. or is intended to be6 a ozw or two rawly dwelling; attached of detached
strtsettsres accessory to such use and/or ram structures A person who comtructo more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building OQlcisk an a form acceptable to the Building
OA'lciak that he/she be responsible for all such work perfomsed under the Building
Permit.
The undersigned "homeowner'assume$responsibility for compliance with the Stag
Building Code and other applicable bylaws and reguladonss
The undenigoed "harneowna"cert111es that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and chat he/she
will comply with said procedures and requirements,
HONEOWYERS SIGNATL'RB (.AA_GIN
APPROVAL OF BUILDLVG INSPECTOR
See other side far state coda
CITY OF S.1C.E,1 f, Ukss wHusETI'S
�' 1 E1rILn i-�;�� 1 `�� 4�JC DfiP.1ATJtENT
120 VVA3uCgGT0V STitEET 3 O FCaOR
' L (978) 745-9595
Q.%f0EU-EY DRISCOLL Fk-X(978) 740-9344
"two"t 11l0.%&U ST.P1ERJt8
DfxECTOR op pLOUC pR0PE9TY/8t:anLvG COS(JJISSIO,YER
Construction Debris Disposal Affidavit
(required tur all demolition grid renovation work)
fn accordance with the sixth edition of the State Building Coda, 730 C1bfR section i l i.5
Debris, mid theprovisiuns of Ib(GL a 40, S 54;
Buildingwor!<shall be permit M
this work is issued with the condition that the debris resulting from
disposed of in a properly licensed waste disposal S 150A. facility as dutincd by ItifGL c
Ill,
1'hu debris will be transported by:
(I1Bt11C U(I1Q41Cf)
The Hubris will bu disposed of in :
(nanln or (jmlity)
-----(I IT-rcsc ui ril,ility)
liguanur n(permit.ipplic.ult
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