14 BEACH AVE - BPA-14-115 INSULATION i r ;
The Cormuonwealth of Massachusetts
�� Y\ Board of Building Regulations and Standards CITY OF
�\ ALEM
Massachusetts State Building Code, 780 CMR Revised Min'SdMar
\ 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Tiro-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date App ed:
Building Official(Print Name) signature
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
\.iV
l.la 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 Prodded
1.6 Water Supply:(M.O.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�Ownerl f Record:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKz(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brie�f\Description of Proposed Workz: �rj}' C
SECTION 4:ESTIMATED CONSTRUCTION COSTS
u Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building $ O, � ` 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 S 2. Other Fees: $
4.Mechanical (HVAC) $ List: r�
5.Mechanical (Fire Suppression)
$ Total All Fees: $
G Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ `��, �1 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Saper•isor License(CSL)
`i� \0
\ ,�`Me t'-�,r�.�� License Number Expiration Date
Name of CSL Holder
^ List CSL Type(see below) V
( n '�'\ `' I�\'� ^ ' Type Description
No.mid Su ct
Unrestricted Buildiu s up to 35,000 cu.ft.
R Restricted 1&2 Family Dwellin
Ci 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 Improvement Contractor(HIC) \ke � (0, b IQ) ,
O \C- l — HIC Registration Nmnber Expiration Date
HIC Company N ie or HIC Re rstrant Name
No.and Str et �„) Email address
J CAM
City/Town,St te,ZIP Telephone r--
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit mast 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�'(�I\`t•—•�-1[1�a' C .0. rtX'�25\OVA
to act on myyj in all matters relative to work authorized by thAttilding permit application.
11 �t Sign -7.
Prhn Oiamei' mie ectrmuc Signature) H e e Date
/ SECTION 7b: OWNEW 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 trite and accurate to the best of my knowledge and understanding.
It Owner's of Allt}InrrZe _ n'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£trod under M.G.L.c. 142A.Other important information on the HIC Program can be found at
w'wuv.mass.gov/oca Information on the Constriction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basementlattics,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"