2 BEACHMONT RD - BPA-2002-1055 14'X16' ADDITION t ip a� --127
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V The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY S M
Y Massachusetts State Building Code,780 CMR
Revised dMar Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolis
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: /
Building Official(Print Name) S immature Date
SECTION 1:SITE INFO TIO
'I Property Address: 1.2 Assesso &Parcel Numbers
4a 9CM&{weNf 1�
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: Q1-
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard '-`t
Required Pided Required Provided Require Provided rov
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 Pf Private❑ Check if yes❑ Municipal dOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: abANt'L 255-
1=66ete A. ^ Sams so-&un .MA 0 70
Name(Print) City,State,ZIP /
y e1. QEACtfatoMtn (a/?1 8.n TAia6 f iLlto ��_ i+ecQei'uS �` hotre� c:<u
No.and Street 4611 -47,21 y egl Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work : /y X 1L r ONE STo2(r ALAI rial/ o✓ <n.u.yeT %y�F
x R A e1Z of Hot/S6
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ Z K 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical ❑Standard City/rown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ 'h List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ K ❑Paid in Full ❑Outstanding Balance Due:
7�'f9c/ e�
e�L-� —ram e-rz_
' Y �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �'.S q 770 f 2 �z -
n c=2Ck (j -"4A-7y License Number Expiration Date
Name of CSL Holder
2bs M622rotAc sf List CSL Type(see below)
No.and Street n ,t T Description
_ Nt w 6d t2Y 12 {41 r{ 0 logo U Unrestricted(Buildings up to 35,000 cu.ft.
Restricted 1&2 FamilyDwellin
City/Town,State,ZIP M Maso
RC Rooting Covering
WS Window and Siding
7 n /� SF Solid Fuel Burning Appliances
S Da��oU tl �I7 G(x{`OS® �a�Igp� Gow I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 L/ �70 3 1 a-I s'-/3
t- -ilE k 64-4 f�'l'-o HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name /t
2 (S tttx/�/LtNttic ST rt' I b(P-+o �ItA It co, co a
No.and Street of- �A of 9� f� z .Sz1
Email a dress
ate,ZI 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 ..........❑ 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNE W 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.
Print Owner's or Authorized Agent'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 fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
wD .mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dps
2. When substantial work is tanned,provide the information below:
Total floor area(sq.ft.) 2 � (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 t IeC+,jc Number of decks/porches
Type of cooling system IJl A- Enclosed Open K
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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MAP 27 MAP 27
LOT 540 LOT 539
1O 50'
MAP 27
* LOT 549
c AREA = MAP 27
5,000± S.F. * LOT 551
01)
Lo
PROPOSED
ADDITION
18't 18't
14'
MAP 27
LOT 548 0 0
18't Dalk
head
5't
1 STORY
DWELLING MAP 27
LOT 550
2
18't 5't
PORCH +1
b
1- 50' 1
BEACHMONT ROAD
P�.(t.OF MASS'n
GPI
S% PLOT PLAN OF LAND
Na a5G43 0 2 BEACHMONT ROAD
I CERTIFY THAT THE BUILDINGS �o R�ctrrx¢'�Jea` SALEM
HEREON ARE LOCATED ON ssroraA«a;os PROPERTY OF
THE GROUND AS SHOWN. JOANNE MELANSON
G �� 1� SCALE 1" = 20' JUNE 18, 2012
DA /RRE—G. PROF. LAND SURVEYOR NORTH SHORE SURVEY CORPORATION
14 BROWN ST., SALEM, MA
(978) 744-4800 #3767