1 BEACON AVE - BPA-13-591 ROOF The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
I`{f Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: _ L�afeApplied: __ _
Building Official(Print Name) Signatu Date
SECTION 1: SITE INFORMATION
L1 Property Address: 1.2 Assessors Map& Parcel Numbers
J 6ea�on e V-0-
I.Ia 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 Prov idcd Required Provided
1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
'Lone: _ Outside Flood Zone?Public❑ Private❑ Check ifyes❑ Municipal 11On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
5ckIx..,....Wlt A--0 11- 0
Name(Print) City, State,ZIP
get,l0V1 fV 3rd- SS
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': ) SrC
-
AC
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 3 g(Q, i 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 $ 2. Other Fees: $
4. Mechanical (HVAC) $ L.ist
5. Mechanical (Fire
Suppression) $ Total All Fees: $
i Check No. _ Check Amount: Cash Amount:___
6.Total Project Cost: $ l�j �(q. 0 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
(�'.,Ari S �ft.Ldr L—D rZ e/ License Number Expiration Date
Name ofer Lis[CSL Type(see below)
AiJcJres Tye Description
n U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvgment Contractor(HIC)
-F d�'S n k Ji C z 5 1 Ui CG.
HIC Compai y Name or HIC Regis ant Name Registration Number
5 ��r ti S. I rn l c i C1o e ( to /Z y
ddres e Expiration Date
Signature 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 R
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... - No........... ❑
SECTION Tai OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
o` P 1)o i n O as Owner of the subject property hereby
authorize ti,- 54--h 0.h-e ✓' to act on my behalf,in all matters
relative to work authorized by&s building peennitapplication.
qxeC lLCJ ( O✓\ng)` `^Ca
I 1
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11o.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basement/attics,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"