B-17-524 - 0038 BEAVER STREET - Building Permit y
(�2 So-7
s� The Commonwealth of Massachusetts
4 At
Board of Building Regulations and Standards " 5 .;< �
Massachusetts State Building Code,780 CMR SALEM
Revise 011
Building Permit Application To Construct,Repair,Renovate Or Dgglihk I A
One-or Two Family Dwelling
. This;acel;toe FQr.Of�'ie�i.Use.:.e
_ 1 Buildtn Permtt(`tuntbeLn
r Date plaed .
.,
suldtrtg 011cal(!'Fiat Nahe) Stgnaiure Date
�ECTIOIV;1 SITE IN3�'(RMATIOi�I
1.1 peaty Ad�d � �� 1.2 Assessors Map&Parcel Numbers
t C�
CD1.1 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Requ'\d Provided Regmiked Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone ,formation: 1.8 Sewage Disposal Syste
Zone: _ Outsi a Flood Zone?
Public❑ Private❑ Check i yes❑ Municipal❑ On site disposal system ❑
SECTI01'�12; PROPERTY OR'NERSHIP .
2.1 w er'of Recor
�Al �
Name(Print) City,State,ZIP
No.and Street Telephone Em Address
SECTION 3;DESCRIPTION F PROPOSED W0R12_(c6eck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.0 Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: �' l
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Qnf
Labor and Materials Y.
1.Building $ 1. Bulltitig Perini;Fee:$ Imdicate bow fee is cetenmmed
2.Electrical $ El 0
Statidacd Gityo-wn ApplteatiaiiFee
C1 Total)?rest Costs(Its E)x.t►ultiplier x.
3..Plumbing $ 2: Other 1~'ees.
4.Mechanical WAC) $
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:.
(Z6. otal Project Cost: $ ❑Paid in Full !J Outstanding Balance Due*
ZO , 000
('1'Z26a PS<UF_ _t-b L�_l
r
SECTIONS: CONSTRUCTION SERVICES
, 1
\\ffiWuneorm
ction Supervisor License(CSL)
C % License Number Expiation Date
Holder List CSL Type(see below)
Type Description ._
No.and Street \
U Unrestricted(Buildings uo to 35,000 cu. ft.
R Restricted I&2 Family Dwelling
city/Town,State,ZIP \ ®RI
Rooli
Roolin Covering
S Window and SidinF Solid Fuel Burning Appliances
Insulation
Tcle hone Email,address Demolition
5.2 Registered home Improvement Contractor(HIC)
HIC Registration Number Expiation Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Tele hone\
SECTION 6:WORKERS'.COMPENSATION 1NSUWCE AFFIDAVIT(M.G.L.e.ISX 2SQ6W.
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Istuance of the building permit.
Signed Affidavit Attached? Yes..........0 No...........0
SECTION 76-OWNER AUTHORIZATIONIO BE.COMPLETED.WHEN'
OWNER'S AGENT OR CONTItACTOIt oPPL1ES:FOIL•BUILDING"-PERIVIIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application. \...�
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
cont ' this application is true and accurate to the best of my knowledge and understanding.
Print vner's or Authorized Agent's Name(Electron Signaturef) Date
O'I S:
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 no have access to the arbitration
program or guaranty fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
www.nmss.eo�'oca Information on the Construction Supervisor License can be found at www.mass.�ovldns .
2. When substantial work is planned,provide the information below:
Total floor 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 halObaths
Type of heating system Number uf,Jecks/porches
Type of coolie;system Enclosed. Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"'