B-19-369 - 0011 BELLEAU ROAD - Building Permit s3L7
;
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SAL ar ar
rev ed 2011
Building Permit Application To Construct,Repair,Renovate Or Demolis a 43
One-or Two-Family Dwelling
`r This Section For Official Use Only
-Building.Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION is SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I e,/ -ea LA XC4 .
(�(1 1.1 a Is this an accepted street?yes no Map Number Parcel Number
1�11 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: PROPERTY OWNERSHIP'
2.1 �wner'of Record: Sc4/ems iD
Name(Print �— City,State,ZIP
fl e1�ea
No.and Street Telephone Email Address
SECTION 3: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:
Brief Description of Pro osed Work':
�/1J ,,, �_ G - Cl S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $
❑Standard City/Town Application Fee 4�? �7o
❑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.r3"3y7Check Amount: Cash Amount
6.Total Project Cost: [$ 35-00- ❑Paid in Full ❑Outstanding Balance Due:
Lf/12 �n ►t�� l� S�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) D /77-7 o23/Z b
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Eric W. Palm Type Description
3 Hfitan St.- U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 FamilyDwelling
City/Town,State @llh M Maso
npf
^� RC Roofing Covering
WS Window and Sidin
9 7(r_�/ ,�q- 3 SF Solid Fuel Burning Appliances
D vl I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
�02d�I 511Z Z
HIC Registration Number Expiration Date
HIC ConwAym
61-R Jefferson Avenue
No.and Street SalemiMA 019-70 Email address
City/Town,State,ZIP 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 f the building permit.
Signed Affidavit Attached? Yes ........... oo' 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 &,I,- ref-/P�
to 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:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
containe }.' this applicatio true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent'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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.jzov/oc Information on the Construction Supervisor-License can be found at www.mass.goy/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,fmished 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"