0065 VALIANT WAY BPA-11-286 V I/1 The Commonwealth of Massachusetts
IIIVVVV ,1� Board of Building Regulations and Standards CITY
�•'!y J Massachusetts State Building Code, 780 CMR, 71h edition OF SALL'M
"'wwwss�� Revised Jainwry
Building Permit App ' 'on To Construct, Repair, Renovate Or Demolish a 1. ?008
On -or Two-Family welling
Section F Official Use Only
Building Permit Number: Date Applied: C
Signature: �/ �/
Building Commissi r/Ins •t of Buildings Date T— 7�
_ SECTION 1:SITE INFORMATION
1.1 Property Address: / 1.2 Assessors Map& Parcel Numbers
1
I.I a 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 11) Frontage(11)
1.5 Building Setbacks(R)
From 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:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
•'�1,��—
Nume(Print) Address for Service:
Sig ature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ,�e5l O kj 2 f: {// .-(' /..p�T
4CL, � .1 eJ /.U �L.Si li 0 C�I'E /NG
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (fIVAC) S List:
S. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S '7 ' 19� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dote
Name ol'CSI.- I lolder List C'SL Type(see below)
T Descri lion
Address U llnrcstricted u to 15,000 Cu.Ft.
R Restricted Id:2 Famil Uwellin
Signature M Mason Onl
RC Residential Roofin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
111C Company Name or HIC Registrant Name Registration Number
)
Address S � ( Expiration Date
Signature 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 ..........O No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building pe it lication.
SiSi a�Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.���✓���
Print Name � .Y�� 0
Signature o Owner or Authorized Agent Date
(Signed under the pains and penalties orpeduryl
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(no(registered in the Home Improvement Contractor(HIC)Program),will Me(have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations i IO.R6 and 110.115,respectively.
2 When substantial work is planned,provide the intormation below:
Total floors 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"maybe substituted for"Total Project Cost"
MOYNIHAN LUMBER OF BEVERLY, INC.
"QUALITY BACKED BYA DESIRE TO PLEASE"
82 River Street P.O. Box 509 FEIN:04-2 261 99 5
Beverly, MA 01915-0509 A AA Contractor Reg No.:
978-927-0032 9H HB Exp. Date:—//—
Salesperson(s):
I HOMEOWNER INFORMATION
Name Daytime Phone
l IE;- I�AI iAs - U/4�
Street Address(Not P.O.Box) Evening Phone
'!�4G�/(4 At A
City/Town State Zip Code Mailing Address(d different from Street Address)
WORK TO BE PERFORMED AND MATERIALS TO BE USED
Moynihan Lumber of Beverly, Inc.agrees to perform the work set forth in Exhibit A for Homeowner and to
use such materials in connection therewith as set forth also in Exhibit A,attached hereto and made a part
hereof.
The following schedule shall be adhered to unless ci umstances arise beyond Moynihan Lumber.of.
Beverly, Inc.'s control:Work scheduled to begin / /_ Expected date of completion.
a be based upon val of special order material
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
Moynihan Lumber of Beverly, Inc. agrees to,�QQe(fQQrm t work, and furnish the material and labor set forth in
Exhibit A for the Total Contract Price of:$ +�i2L.s� (which amount includes all finance charges).
Paymentsall boe�made by Homeowner according to the following payment schedule:
$ ,519 0. Initial deposit upon signing this Contract(the initial deposit shall not exceed the greater of
one-third(1/3) of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom
Or e _as�sgt forth below).
$ 4 ry by_LLor upon completion of delivery of materials
$ by_/ / or upon completion of irystall• _
$ upon completion of the Con....... A
In order to meet the completion schedule set forth above, the following materials/equipment must be special
ordered before the Contract work begins,for a Total Cost of Special/Custom Orders of$
$ to be paid for building permit
$ to be paid for
$ to be paid for
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
��6�0 Moynihan Lumber of Beverly,Inc. v
Homeowner's Signature Date Contractor �7 Date /
Homeowner's Name(Printed) Nam Printed)and Title of Signatory
You may cancel this Contract if it has been signed by a party thereto at a place other than an address of
Contractor,which may be its main office or branch thereof, provided you notify Contractor in writing at
its main office or branch by ordinary mail posted, by telegram sent or by delivery, no later than midnight
of the third business day following the signing of this Contract. See attached notice of cancellation for
an explanation of this right.
1057-BEV 4/09 White-Office Yellow-Sales/Service Pink-Customer Page 1 of 5