B-17-935 - 0066 BEAVER STREET - Building Permit The Commonwealth of Massachusetts 4
6
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780, P SALEM
Ep 2` Revised Mar 2011
Building Permit Application To Construct,Repair,Rei-ovate Or Demolish a
t One-or Two-Family Dwelling
Ttvs Section Fpr Qfficial Ile Onl,`=. 2
Building Permit Number 1 Date A Iced
Building Official(1'rmt Name) � Sigaatuie �; �' Date
,e SECTION 1,.SITE INFORMATION s
t 1.1 Prgp rty Address: 1.2 Assessors Map&Parcel Numbers
8CA62Sf.
1.1a 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
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2 PROPEI TX QW ERSHIP1
2.1 Owner'of Record:
CAROL XUARD SAL ed M1? . 011,70
Name(Print) City,State,ZIP
6G BM VC-R sr 978,410- 783Y
No.and Street Telephone Email Address
SECTION 3:DESCRI<PTION OF PROPOSED;"VVORI{?(check all t. apply);.
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other lif Specify: - l j�RI Z&T- 6,1/
Brief Description of Proposed Work2:
TAIS0447-L &TTiC .} ,EX71RIJA &M--f li7-d 01Af.a CELCIILO-:rf,
SECTION 4.:ESTIMATED-CONSTRUCTION COSTS
Estimated Costs
Item Official Use Oily
Labor and Materials
1.Building $ �OD 110
1 Building Peirnit Fee $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Tawn Application Fee"
l7 Total Protect Costa(Ite -�6)x triultipher x
3.Plumbing $ 2 Other Fees r$ _
4.Mechanical (HVAC) $ List
5.Mechanical (Fire
Su ression $ Total All Fees:$.
Check No Check Amount Cash Amount:
6.Total Project Cost: $ 600 ° 13 Paid in Full 0 Outstanding Balance Due
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor,.'License(CSL) .,
License Number Expiation Date
N;me of CSL Holder List CSL Type(see below)
1571YORI64 R-b Type• : Description .
No.and Street
��,/� OC gp U Unrestricted(Buildingsa to 35,000 cu. tt.
lWAKEFt&,b , Yr a b R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP �It Nlasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered home Improvement Contractor(HIC) / /0 S 0 ,j 10-19-19
5'06CA 0,OnJ7-AA("1 AI6 C0- HIC Registration Number Expiration Date
111C Compan Name or HIC Re istani Name
326 6 /7ASH1106TX rS 7- r -q
No.and Street Email address
AA b LAI
City/Town, State,ZIP Tele hone
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 Is§uance of the building permit.
Signed Atiidavit Attached? Yes .......... No...........C3
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEN"
OWNER'S AGENT OR CONTRACTOR APPLIES:FOIE BUILDING.PERMIT
I,as Owner of the subject property,hereby authorize r/CCfI �iU"i 'ACy"tAA,4- C� • -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
(i�t�z lwa JLJ, -- -/1-/7
Print Owner's an lectronic 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
contained in this application is true nd accurate to the best of my knowledge and understanding.
AW A)a f ICN El 711 %- 9-17
Print Owner's or Authorizcd Agen s Name(Electronic Signature) Date
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 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
xvww.mass.cov'oca Information on the Construction Supervisor License can be.found at www.mass.1ovhltns .
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 half/baths
Type of heating system Number of decks/porches
'type ofcooling system Enclosed Open
3. -Total Project Square Footage"may be substituted for"Total Project Cost"