B-19-278 - 0033 BELLEAU ROAD - Building Permit The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
�. Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For;Official;Use Only
Building Permit Number. Date Applied:,,
Building Official(Print Name) Signature pate '
4CrSECTION''1:SITE INFORMATION
A..1 Pr ert Add
Y ress: 1.2 Assessors Map& Parcel Numbers
T
`1:1 a is an accepted street?yes no Map Number Parcel Number
Phing Information: 1.4 Property Dimensions:
N
ZoniwgDistrict Proposed Use Lot Area(sq tt) Frontage(tt)
'1.5•building Setbacks(ft)
Q
p 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?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2:;'PROPERTY:OWNERSHIP'
2.1 Owner'of Record:
iP yih r�n����r SoK0tyy1_.�Lk-f C) 19L In
Name(Print) City,State,ZIP
33 Qeke_-u- M m
No.and Street Telephone Ertfail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(cheek all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: .�
Brief Description of Proposed Work2:
0,S o&a s t .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use.only,
(Labor and Materials) Y
1. Building $ -� V. Building Permit Fee: $��lndicate how fee is determined:
2.Electrical $ ❑Standard City/Towne Application Fee
❑Total Project Costa(item 6)x multiplier x
3. Plumbing $ .`2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression $ Total All Fees:$ _
Chec o Check Amount: Cash Amount:
6.Total Project Cost: $ y 4 —1 aid in Full ❑Outstanding:.Balance Due.
v Z1 M,LXILOD TOCa •C-
SECTION 5: CONSTRUCTION SERVICES.
5.1 Construction Supervisor License(CSL)
cs-ostig$cil- {Irtao�Ck
Rrl QVN� Le-8 License Number Expiration Date
f Name o CSL Holder
Name
of r List CSL Type(see below) U
t
T e Description
No.and Street . >>
U Unrestricted(Buildings up to 35,000 cu.ft.)
_11\�/`Qx',S /�+��+��� ,3 R Restricted 1&2 Family Dwelling
City/Town,State,ZIPS M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
977$'-91!L TRb QLCr_" 'Z l Insulation
Telephone Email addres '-Zov,, D Demolition
5.2 Registered Home Improvement Contractor(HIC) '
C aLS-1-1� �\-s-� C. s6 s g ao
A C. b�/\ � ��p,Gt. HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
oo 0 aeO�CCr�� sL
No.and Street Email address
l.e_I
City/Town,Sta1q,ZIP Telephone
SECTION 6 WORKERS'.COMPENSATIONJNSURANCE 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 the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a OWNER AUTHORIZATION"TO
BE COMPLETED WHEN
O,WNER'S AGENT OR,-CONTRACTOR APPLIES FOR BUILDING»PERMIT
I,as Owner of the subject property,hereby authorize A,�-. (A�-�-� ��L�S�-►e 8z,.�i v�e�9��
to act on my behalf,in all matters relative to work authorized by this building permit application.
kp-AA If\ MX_A_a\esn � 3 -a-o /k C1
Print Owner's Name(Electron4 Signature) Date
SECTION 715:OWNER';OR•AUTHORIZED AG ENY)JECLARATION
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 and accurate to the best of my knowledge and understanding.
y-s+ie. �w;e�e� 3 IaQ 119
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES...
l. 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
wvv .mass.gov%oca Information on the Construction Supervisor License can be found at ww��.mass. ov/dps
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 of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
?5'a S$