14 BEACH AVE - BPA-13-1019 ROOF 1 The Commonwealth of Nfassachusetts CITY OF
� . Board of Building Regulations and Standards SALEM
j Massachusetts State Building Code,780 CNIR Revised filar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
i
One-or Two-Family Dwelling
This Section Forbfticial Usa Oni
Building Permit Numberv'. Date pphed).
Build ng Gfficial(Prin(Name) Signature;.:. _ Data
SECTION l:SITE INFORIN ON
1.1 Property Address: / 1.2 Assessors Map 3c Parcel Numbers'
L I a 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(it)
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 ifyes[]
SECTION 2., PROPERTY-OW NERSHIP"
2.1 Owner'of Record: p
7'r.�r,..`fi.e �ot„,i ' r- ��/ /.+Clca� ig-•�•c S/�-/ram
Name(Print) City,State,ZIP -
-7 - 7<G - 922 6S-
No.and Street - Telephone -Email Address
SECTION 3: DESCRIPTION OF PROPOSED.WORK°'(check all that apply)
New Construction❑ Existing Building❑ Owner•Occupied O Repairs(s) Cl Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other pecify:
Brief Description of Proposed Work': e
SECTION4: ESTINIPTED CONSTRUCTION COSTS
[tern 7cl
Offtclal Use Only..,
1. Building L,Building Permit Fee:S' ' Indicate how fee is determined:
Fh�triwl Standaid,,CityClotvnAppiicationFe&2. .
❑Total Project Costt(Item.6)s multiplier x
3. Plumbing 2• Other Fees: S
I. Mechanical (11VAList:
i. Mechauical (FireTotal;\IlFees: .S5n ression) Check No. Check Amount: Cash Ainounrf, -Cutal Pt ojcct Cu ❑ P-ud m Fall Cl Uutst.uulin„ Il ilinec I>ua
��
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /a _ V
�� OO� I�/v _ License Number E irt
ZU
Name of CSL I(older
/ List CSL Type(see below)
WSFSolid
Description
No. m reef
r��1�� /��/ ted Buildingsu to 35,000 cu. 11.)
l ] d 19t2 Famil D%vellin
City/rovvn,State,ZIP
Cuvcrin
and 5idin
el Flaming Appliances
I Insulation
Tula hone Email address D Demolition
5.2 Registered Home Improvement
/Contractor(HIC) 63�6�
M de(C no 0e HIC[registration Number xp' ation Date
(1(C Company Name or FIIC Registrant Name
No.and / �7 S F 7 G Email address
City/To n.StateZIP (� 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 'lding 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 Ida
to act on in:If, in all matters relative to work authorized by this building permit application.
Pri e , Me(Electronic Signature) Dale
SECTION 7b: OWNER' OR AUTHORIZED'AGENT DECLARATION
By entering my name below, I hereby est>lxqr the pains and penalties of perjury that all of the information
contained 61A icntio ' ru d a• tr e t e best of my.knowled8e and understanding.
/�,
I' t tc 's or Author' :\,cnt's N.0 Electronic Signature) ate
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Hone Improvement Contractor(H[C) Program), will n_rt have access to the arbitration
program or guaranty rind under NI.O.L. c. 142A. Other important information on the HIC Program can be found at
wwvv.mass.cov/oua Information on the Construction Supervisor license can be found at avvw.mas .-ovIL
3 When substantial work is planned,provide the information below:
rot:d tloorarea(ml. ft.) _(including garage, tinished basement/attics,decks or porch)
tiro;; living area(sy. tl ._ Habitable room count _
Number of tirc laces Number of bedrooins
Number of bathrooms Number of Italt-baths
I'cpc of heating sy;tcm .. - . _.--.-- Numbcrufdsk.;'purihus
I\peotutolin�; ;yuent , .-_,.--- Enclosed_ -- -- 1pen --__--. .—.---
I. l ot.il I'r q:rt 5yu.iro Prnrt.i a" wary he snb;tiun:tl r;,t'" I.aal Pwjed Co;t-