2 BEACHMONT RD - BPA-12-404 REBUILD PORCH, RAILINGS, ETC 1
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The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
1\ Massachusetts State Building Code, 780 CNIR SALEM
Reviser!.War 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number:
Building Official(Print Name). Sighature-, _ Date
SECTION 1:SITE INFORMATION
I.1 Property Address: 1.2 Assessors Map& Parcel Numbers
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1.1 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 11) Frontage(11)
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 Zane Information: 1.8 Sewage Disposal System:
Public Zone: _ Outside Flood Zone? P p y Private❑ Check ifyes❑ Municipal❑ On site disposal stem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner[of Record: 5�(✓�
.'"TD�0"AJIJ MFLA+R-ct/ l2iCltie.P�ejjn - M�
NT�hme(Print) City,State,ZIP
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No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': /ZEMD i?EL / ZEBV I6.0 0 i= J=q 0 A/i
C STALL. AI c w F01)V NCS F''YM ^4
655 ' [ —1L C aV % -� 51k AJ
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Nlaterials
I Ruilding S — I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard Cityfrown Application Fee
❑Total Project Cost"(Item 6)x multiplier x
3. Plumbing S 7. Other Fees: S
4. Mcchanical (FIVAC) S List:
5. Mechanical (Fire S
Su ression) Total All Fees:S
Check No. Check Amount: Cash Amount:
(. Total Project Cost: S c;2 00 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS 0�q 320
License Number Expiration Date
Name o t'CS L Holder u
List CSL"Type(see below)
P° Soy( I
No.and Street Type: Description
U Unrestricted(Buildings up to 35,000 cu. It.)
Na JLd !t M e)4 l`I i—b R Restricted I&2 FamilyDwelling
Cityll'gwn,State, P M Masonry
RC Roofing Covering
WS Window and Siding
�Zg ��I? ,( I SF Solid Fuel Burning Appliances
-r °6 LY ( 6 qt.-k,S d�l e knb � 1 Insulation
'rcie hunt Email address D Demolition
5.2 Registered dome Improvement Contractor(HIC) q q?tr 3 '6 1
0 Ba vwk'C',-�- HIC Registration Number Expiration Date
f11CQCorwai yrilICRegistrantName
--P ASS I � I b c-�t'�-"0�t'� �Q(•t DO•� Cv(a�
No.and S reet Email a ress
i rt LAI Sa.S 1;"01-13
City/Town, Std e,ZIP rele hone
SECTION 6:WORKERS'CONIPENSATION 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 CONIPLETED W HEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize�G/� I Vi
t9 act on my behalf, in all matters relative to work, th rized_by-this Building permit application.
! A 11113113
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.
1/ l l3
Print Owner's or Authori2ed 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. I42A.Other important information on the HIC Program can be found at
scww.mass.,�ov'oca Information on the Construction Supervisor License can be found at www.mass.,,ov'd to
2. When substantial work is planned,provide the information below:
Total floor area(sq. aJ (including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) 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="Tuf:tlProject Cost" -
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