12 BEACH AVE - BPA-14-139 ROOF The Commonwealth of Massachusetts
i
CITY OF
Board of Building Regulations and Standards
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 Pencil Number: Date Applied: �y
• d
Building Official(Print Nam Signature Date
SECTION 1: SITE INFORMATION
1.1 Propert Addres): 1.2 Assessors Map& Parcel Numbers
L l a Is this an accepted street?yes_y 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 yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
pC\ kZI c0., Gl o lw.n, s So )ev. MA Ot 01 ? U
Name(Print) City,State,
/a- Ave- 7£sl 9g3gAg
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repatrs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'`: e- cccP. C %z-r
1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: ..,Official Use Only
Labor and Materials)
1. Building $ 'K 100 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: 46-X o
5.Mechanical (Fire $
Su ression) Total All Fees:$
p Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ O 100.0 ❑Paid in Full ❑Outstanding Balance Due:
�`. �0% Q
i
SECTION 5: CONSTRUCTION SERVICES
5..11 Construction Supervisor License(CSL) 066�O 3 I S
✓ E.y�e 5 6"yew` License Number Expiration Date
Name of CSL Holder (,
List CSL Type(see below) On f LiS�r1 Ll
t./ cross Awe
N and Street Type Description
,� U Unrestricted(Buildings u to 35,000 cu.fi
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Cl7 f 735- 03S77 -tMQv--JT-RC 2 79,W I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or I IC Registrant Name
(.l t^_C'O S5 V Y1't (;41 —S—Z e,-5.Cc)
N and Street Email address
IieN, MA o(a7r) 47773so�5
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 ..........X, No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize JR Q tnn, !✓{
to act on my behalf, in all matters relative to work authorized by this building permit application.
z,� � 3)113
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
B entering m name below, 1 hereby attest under the pains and penalties of perjury that all of the information
Y g Y Y
` contained in this application is true and accurate to the best of my knowledge and understanding.
7 -a8- �3
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.gov/oca Information on the Construction Supervisor License can be found at www.niass.gov/dos
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 S:ULE;%I, N-LAss k -IUSETTS
BUILDING DEP ART-,IENT
120 WASHINGTON STREET,311e FLOOR
TEL (978)745-9595
Fsax(978) 740-9846
KINfBER1 LF-EY DRISCOLI
MAYOR THOMAS ST.PIE "
DIRECTOR OF PUBLIC PROPERTY/BuIIDING COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 Please Print Legibly
Narne(Busiiws&otganiratiutvindividual):_/� ,\�
Address: .MUSS
City/State/Zip: SIP.Inn Phone hl: C17 g 7 y S 7 v2F
Are you an employer?Check the appropriate box: Type of project(required):
I.0 1 am a employer with cz 4. ❑ I am a general contractor and 1 6. ❑Now construction
employees(fell and/or pan-time).' have hired the sub.c:ontractors
2.❑ I am a sole proprietor or partner- listed on the attached shceL t 7• ❑Remodeling
ship and have no employees These sub-contractors have lf. ❑Demolition
working for me in any capacity. workers'comp.irniumnce. 9. Building addition
(No worker'comp.insurance 5.'❑ We are a corporation and its
rcqulretL). officers have exercised their l0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL. I I.[]Plumbing repairs or additions
myself.(No workers'camp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]
req u t umployeem(N**ortiers',-
i
l3.❑Other,
comp:insurance required.)
Any applicant Ihu chmka box s l mull also rill out the sociluo blow showing their workers'compeiwion policy inturmatfon.
I hvneuwnen whoeubmil Ihii atildavit indicating they eta doing all work and then hhv oulfideeonttaCnn tnou,uhmil a new afrtdavil indicting such.
!Conimutors that check ibis box most attached an addidunof sheet showing the time of the sulscantraebra and their work mi'mmp,policy Infotsnauan.
1 um an easp/ayer that Is provlding ivorkers'compensaton Insurance for my employees- Below/s the policy and fob We
injorcrcutfom /��
fn,urance Cumpany Name: e 1�c b� '(, Vnv (c tf�u�y�-(-1 -7 ,/
Policy A ur Self-its.Lic.N: w 4i 1� or) e4j ey -f-t-' — Expiration Date' ! 3 a - i�1 '
Job Site Address: � 2 ec c� p Tl�e_ City/Statrizip.. Sq(PM Mgt
,lttacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to SI,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S230.00 a day against the violator. Be advised that a copy of this statement may,be forwarded to the Office of -
Investigations of the DIA for insurance coverage verification.
I do hereby c'ertijy under the pants and penehles of prrfury that the Information provided above is true and correct.
Sign durr' Duto•
Phoned;
only. Do not write its Kris arro,to be completed by city or town offlelat
City or'Tawn: Permit/f.lcense _
Issuing Authurily(circle one):
I. Bourd of Health 2. Building Department 3.Cilyffown Clerk 4. Electrical 6lspector 5. Plumbing Inspector
6.Other,
Contact Person: - Phone B'
i
_ C(TYOF ��tks&wHUSETTS
;f;' Bt:lLncvc DEPA-ATStENT
.� I:'0 10
CV14H6VGTOVSTREfiT 3 F1.00t
` 1RIL (973) 1;5-9593
XIMO&U-EY DRISCOLL FU't(973) 7•10.934d
,�r L�Yo;t 'tXto�cct Sr.Pt�.ans
DILCTOR UPPCOLtC PROPE4Ty/8l'ILDLVG CO.%011SSJO.iER
Construction Debris Dispasai Atf7davit
(rcyuiriid for all demalitiun turd ronuvetion work)
in accardanca with tits sixdt editiun afthe State Building Cada, 730 CMR section 1 I 1,3
Debris, and the provisians of MGL e 40, S 54;
Building Permit bi is issued with the condition that the debris resulting Pram
this work shall be dispascd Of in a properly licensed waste disposal facility as duBncd by ,tifGL a
l l I, S 150A.
Thu debris will be trinsportcd by;
(lama ul'haulur)
The debris will ba disposed or in
(name ae ricaily)
— W�•V✓t,P 5 CO
(iLlr�s.t urr.i,iLry)
i•pumre irpanuir.ipplie.rnt