24 BELLEAU RD - BPA-11-15 REPAIR WATER DAMAGE BASEMENT The Commonwealth of Massachusetts
f I� j Board of Building Regulations and Standards CITY
l Massachusetts State Building Code, 780 CMR, 7'h edition OF SALEM
Revisad Januury
1 Building Permit Application To Construct, Repair, Renovate Or Demolish a /• 't/f/
One-or Two-Furrrily Dwelling
This Section ForJAtWial Use Only
Building Permit Number: Da Applied:
Signature:
Building Commissioner/Inspcel&r4f Building - Date
SECTION/-SITE INFORMATION
1.1 9ryspgrty�rQdt�gspl eau 1.2 Assessors Map& Parcel Numbers
V 1.la Is
sst�his an''accccepptt.•ed{ street?yes V no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(ft)
Front 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 13 Private❑ Check if yes❑ Municipal❑ On site disposal system 13
SECTION 2: PROPERTY OWNERSHIP'
2.1 �erofR ord: ^ Q5 �� /fie/ lee t R _/
Name(Print) 1. Address for Se/rv`icce• CJ/
�uu - a �-.�..co
Signature _ 'relephone
SECTION 3i DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Bri Description of Pro osed Work':
� --
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S I. Building Permit Fee:$ Indicate how fie is determined:
❑Standard City/Town Application Fee
2. Electrical S t
❑Total Project Cost (Item 6)x multiplier---- x
3. Plumbing S 2. Other Fees: S /\^J
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S
l 000
r 0Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor(CSL)
License Nunher Expiration Date
Name of CSI.-I]older
List CSL Type(see below)
1\PC I Description
Address Il Unrestricted(tip to35,000 Cu.Ft.)
It Restricted I&2 Family Dwelling
Signature M Masunry Only
RC Residential Rooting Coserin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I I1C Company Name or f fIC Registrant Name Registration Number
Address
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 .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , 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.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
C ccn Q S ,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
IT r
Sian• u oFOwner or Authorized Agent Npkl� bi(_- Uateo(
Sind oder the sins and enalties of er'u va
NOTES:
I. An Owner who obtains a building permit to Jo 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 I IO.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Fl.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Ty pe of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"