22 BELLEAU RD - BPA-11-529 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 71"edition OF SALEM
Revised January
1 Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
qOne-or Two-Family Dwellin
This Section For Official Only
Building Permit Number: Date Ap ied:
Signature: 'Id 1)D//[�
Building Commi sioner/Inspec of Buildin s Date
SECTION ITE INFORMATION
1.1 Property Address: (\�` 1.2 Assessors Map& Parcel Numbers
2 e,\� 2c V �L1cACV
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided RequiredProvided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public$1 Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal BC On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: n
Name Ad_dr9ss for Service:
� lR - -1 � S- �lb1b
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ —_ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
ssion $
SupreTotal All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ C� 3 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
�Lu v c,S T--S { t/1 License Number Expiration Date
Name of CSL-Holder T'
Lis[CSL Type(see below) \�
ddress ` Type Description
U Unrestricted(up to 35,000 Cu.Ft.
_ R Restricted 1&2 Family Dwelling
lure M Masonry Only
�-
9S � -Obn Q) RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Companye or HIC Registrant Name Registration Number
ddress �--
-O�c.� -� Expiration Date
i ature 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 ..........IQNo...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, \ e as Owner of the subject property hereby
authorize_� � _ c e�� l,� a :z �C �� to act on my behalf,in all matters
relative to work authorized�y this ilding permit application.
Si at of er Date ��)/
SECTION 7b:OWNER[ OR AUTHORIZED AGENT DECLARATION
&9—C ,C�0-f 0 ,as Owner or Authorized Agent hereby declare
that the statements and information on We far ing application are true and accurate,to the best of my knowledge and
behalf.
Print N
Signatur o wner Authorized Agent Date
(Signed under the pains and penalties of
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 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information 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"