7 BEACH AVE - BPA-16-141 REPAIR CRACKED FOUNDATION $2-ZLi 00 C_
The Commonwealth of Massachusetts
° Board of Building Regulations and St VED SERVICES CITY OF
Massachusetts State Building Code; $ SALEM
Revised Mar 2011
i Building Permit Application To Construct, Repaie �atgQrm�2h
One-or Two-Family DweI
_:This Section For Officia se Only
r Building Pemut N I Date pphed
1 Building Official(Pnnt Name) ! Signature ,
SECTION 1:SITE INFORMATION=
I 1.1 Pro per dre ,: e / /7� 1.2 Assessors Map &Parcel Numbers
L l a Is this an accepted street?yes <no ,( Map Number Parcel Number
I 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:
Zone: _ Outside Flood Zone?
Public[3 Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
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SECTION 2 'PROPERTY OWNERSHIP',-
ic
Name(Print) City,State,ZIP'
No.and Street - Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKx(check all that;apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Oth ❑ Specify:
Or-
Brief Descnp 'on roposed Work :
H
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 3Z i 1. Building Permit Fee: $2, y Indicate how fee is determined:
❑ Standard City/Towo Application Fee
2.Electrical $
❑Total Project Cosy'(Item 6)x multiplier ' x
3.Plumbing $ 2. Other Fees.:$ AA
4.Mechanical (HVAC) $ List: '
5.Mechanical (Fire Suppression)
$ Total All Fees: $ -
6. Total Project Cost: $ cV Check No Check Amount Cash Amount
b Paid in Full ❑ Outstariding Balance Due.
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MA,tx„, )� -61L
SECTIONS: CONSTRUCTION SERVICES
5.1 C9nstruc on Supervisor License(CSL)
✓a'M . �/*,f/�e License NumberExpiratio Date
i Name of CSL Holder / r
List CSL Type(see below) l/t
No. dS eelt ,,✓✓/c/` ,-vFT'pe { .,5, MPM �.r.,e, Description a.,mg.,.. "
U Unrestricted(Buildings u to 35 000 cu.ft. x
Q R Restricted 1&2 Family Dwelling
Cityaown,State,ZIP M Masonry
RC Roofm Coverin
WS Window and Siding
2 ` ��/ /�, SF Solid Fuel Burning Appliances
p -Im 7/e ryNZvC� //�j 41&? I 1 Insulation
Telephone Email address V D Demolition
5.2 Re istered Home Inpprove ent Contractor(HIC) r MV (4 `
HIC Registration Number E pi• 'on Date
HICi frpan ame`o`r HIWC gi strif Name
NoAdd S eet ,q� ,Ltvd �,ry, �31� � Email address
City/Town, S te,ZIP (� Telephone
,.,..�...w
20. SECTION 6 WORKERS'COMPENSATION INSURANCE AFFIDAVITc.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 ..........X No...........❑
t i (SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT,OR CONTRACTOR`APPLIES FOR BUILDING PERMIT ' `r#
I,as Owner of the subject property,hereby authorize ��An 7 Hlt&-e
to act on my behalf,in all matters relative to work authorize by this building permit application.
Print Owner's Name(Electronic Si ature) Date
r,SECTION7b:OWNER,ORAUTHORIZED AGENT DECLARATION
t. .
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 ac to the knowledge and understanding.
V o4i, v! •Cde
Print Owner's or Authorized Agent's N TtE lectronic Signature) Da e
� .. .. .....;m... ,.„I VN.. z__s.�. n ,;i`s': 'NOTE5
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.gov/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"
1