5 BEACHMONT RD - BPA-15-267 REROOF GARAGE V1 cK q -7
'rhe Common%vealth ofMassaehusetts INSPECTIONAL ERV..
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR 2015 APR —q ekse2.9rr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
1 This Section For Official Use Only
l v Building Permit Number Dak Applied.,
Building Otlicisl(Pont Rame). Signature- ." . . Date
SECTION I:SITE INFORMATION
I.1 Property Address: 1.2 Assessors Map Rr Parcel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
"Coning District Proposed Use Lot Area(sq 11) Frontage(R)
1.5 Building Setbacks(it)
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:
Zone: _ Outside Flood Zone? MunicipalCl On site disposal system ❑
Public❑ Private❑ Check if es❑ y
SECTION2: PROPERTY OWNERSHIV
2.1 Ownert or Record: I�A
t�tlme(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
BrieF�De�scription of posed Work2: C_�7,A D A 6sp
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 20 I• Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost"(Item 6)x multiplier x
3. Plumbing S �,gther Fees: S
4. �Icchanical (HVAC) S List:
5.i\lechanieal (Fire S
Suppression) 'fatal All Fees:S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: .'S 4( ( 5a 00 ❑Paid in Full 0 Outstanding Balance One:
r
T
t.
SECTION 5: CONSTRUCTION SERVICES
5.11CConstruction Supervisor License(CSL) _A—7 6`?-
l.JtSbb(wS c a .Z License Number Expiration Date
Munc of CSL Holder List CSL Type(see below)
.S� Type - Description
No and Street
C7 1 9 j, o U Unrestrieted BuilJin s o to 35,000 cu. 11.)
P A h O IJ I r� R Restricted M2 Famil Dwellin
Cityffown,Stale,"LIP M Masonry
RC Rootin Covcrin
WS Window and Siding
SF Solid Fuel Burning Appliances
9 , 5 3 � '-aa314 I I Insulation
'rcle hone Email address D Demolition
5.2 Registered home Improvement Contractor(HIC) _ l 0 D 9 ( ( 23—�b
L.e, GL-, b.L Y eew(, H1C Registration Number Expiration Date
f 11Company Name or HIC Registrant rZ Sant Nave
r r �
Nu. ad Street Email address
MA 0 1 Z) tT3 t R;43�t
City/Town,State ZIP Tele hone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.C.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 Isluance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATIONTO BE CONIPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7D:OWNERI ORAUTHORIZED AGENT DECLARATION
By entering my name below, 1 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 any knowledge and understanding.
Print Owner's or, uthorized Agent 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 H[C Program can be found at
www muss eov'oca information on the Construction Supervisor License can be found at wsvw.mass.�!ov�'dos _
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. ft.) 4, (including garage, finished basement/attics,decks or porch)
Gross living area(sq. it.) Habitable room coma
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 Enclose) Open_
1. "folal Project Square Footage may be substituted tiu"'rutal Project Cost"