44 BEAVER ST - BPA-11-507 REPAIR CHIMNEY The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY O 1 Massachusetts State Building Code,780 CMR,7"edition OF SALEM
Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwellm
This Sectio or Official 1,4e Only
Building Permit Number: ID e lied:
Signature:
Building Commissioner/Inspe or of Buddi s Date
SECTION 1: ITE INFORMATION
1.1 Pro Address• 1.2 Assessors Map&Parcel Numbers
Lla 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Y
MunicipalP❑ On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
TLL kj�L.Noy6Rc �t� �AuE t? SAI fm M
Name(Print ,�� pp Address for Service:
�IAT�I� 9��-7 '=15 - L-O
ature Te epi hone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that appl )
New.Constmction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteratio,(s)X I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Des ption of Proposed Workz:
fhpd� im1 32[cL ewimlizm tdim uba)
CNnl" cll
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ G a 1. Building Permit Fee:$ Indicate how fee is determined:
13Standard City/Town Application Fee
2.Electrical $
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �� 000 ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /h F7 �6�� 2-
3p(4:
—
Vp(4: F�, -6&(§r[ ( License Number Expiration Date
Name of CSI,HH,older^'�, List CSL Type(see below)�L
Address !'Lbs Type Description
U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Si atur c-- M Masonry Onl
-29/ i a/ RC Residential Roofing Covering
Te one WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5..2 istereTff ,lin meat Contractor(HIC)
HIC Company Name orH Registrant Name Registration Number
Address
l4- z_
Expiration Date
Sign a Telephone
CTION 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
1, M640aLi K Uas Owner of the subject property hereby
authorize 1 L4ZY7 ( to act on my behalf,in all matters
relative to work authorized by this buildinglication.
Si ature of O Date
SECTION 7b: OWNER'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.
O � �A-FiLi�2
Print Name
Signature Pf O r or Authored Ag Date
(Signed der V pains and penalties
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 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 information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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"