B-17-848 - 0026 BELLEAV ROAD - Building Permit Y
The Commonwealth of Massachusetts
Board of Building Regulations and;Stand r ` y: FOR
U7° h �- MUNICIPALITY
Massachusetts State Building Code,780 , s ,r
USE
Building Permit Application To Construct,Repair,"ppVp Or Penlolipjt a Revised Mar 2011
One-or Two-Family Dwelling !!-�� !!1 2
°
This Section F.or O icial Use Only
s
Budd ng Permit IVum er to Applied
(/ t $uildm Official Pnnt Name : S�
$f ( . ) gnature Date
S SECTION 1.SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers
1 Lla 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 PROPERTY OWNERSHIP'
2.1 Owner'of Record:
1 We( nnt) City,State,ZIP
741 I I G
o.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2: ►��
v.
z
�► c
SECTION 4:V"RTIJIF L&D CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $1'7rt Oe 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town 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:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
Z33. -75 1
y
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L
SECTION 5: CONSTRUCTION SERVICES -
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covens
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street 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 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.
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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.pov/dl2s
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"
1
SECTION 5:: CONSTRUCTION SERVICES
rCo struction Supervisor License(CSL) License Number Expiration Date
e of CSL Holder
!,U �v � List CSL Type see below)
No.and Street Type Description
A �w�4� pn a �CA J C U Unrestricted(Buildings u to 35,000 cu.ft.
�\ J R Restricted 1&2 FamilyDwellm*
City/Town,State, M Masonry
RC Roofing Covering
WS Window and Siding
� " SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home mprovement Contractor(HIC) ,(,�/
?d NA 6 0,5 CO—!5.1 HICC Registration Number lExp" iration DateD
111 Compaqy.Aame 9T HICga istrant Name
- B tJ,,C
No.and Street Email address
Ci 'Town,Sfaie,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 Issuanc a 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.
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
contained in this application is true �J,
and accurate tb the est mykn ge and understanding.
t� r � cllIl 1 -7
Print Owner's o Authorized is Name(Elec Signature) Date
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.mgg.ggv/oca Information on the Construction Supervisor License can be found at www.mass.gov/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"
CITY OF SALEM MASSACHUSETTS
DEPARTMENT OF PLANNING AND
COMMUNITY DEVELOPMENT
IC[MBERLEY DRISCOLL 120 WASHINGTON STREET ♦ SALEM,MASSACHUSETTS 01970
MAYOR TELE:978-619-5685 ♦ FAX:978-740-0404
TOM DANIEL,AICP !
DIRECTOR 7
SALEM HOUSING REHABILTTATION LOAN PROGRAM
NOTICE TO PROCEED
Date: August 31 s, 2017
Case#: 17-06E, 26 Belleau Road, Salem
Contractor: Perry Brothers Construction, Inc.
Dear Bill,
You are hereby given authorization to proceed with renovations to 26 Belleau Road in
Salem,MA in accordance with the agreement.dated Augjjst 7, 2017. As stated in the.
aforementioned agreement,work is to commence within 14(fourteen) days and be completed
on or before 30(thirty)days subsequent to the date of this proceed order.
Thelma Naomi Francis96
Housing Coordina
This program does not discriminate on the basis of race, color, national origin,gender orgender identity, age,
C religion, marital status,familial status, sexual orientation,ancestty,public assistance, veteran history/military
status,genetic information or disability: This program is funded through the United States Department of
Housing and Urban Development(HUD), utilizing HOME and Community Block Grant Funds(CDBG).