17 BEAVER ST - BPA-11-833 ROOF, SIDE, WINDOWS ,
The Commonwealth of Massachusetts CITY OF
ry fq ,i - Board of Building Regulations and Standards
Odd/ �p�QI Massachusetts State Building Code, 780 CMR SALEM
Revised Alnr_Ol!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Otte-or Two-Fantily Dwelling
This Sec ' n or Official Use Only
Building Permit Nunt er. 1 7 4 Date Applied:
Building Official(Print Name) Signature Date
SE&H-1 I: SITE INFORMATION
1.1 Press: 1.2 Assessors Map& Parcel Numbers
I.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 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 Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if ycs❑
,QSECTION2: PROPERTY OWNERSHIP'
2.1 Owner of,Record: �t��S6r`1 �P/f✓ S�-.,�f`P�S �01 SPZ / �' � ,/
�gMA., 1�rrn F6p) 6au Q
N:uu6ninq - - City,State,ZIP
No.and Sytree Telephone Email Address
0 ,&&s .AECTION 3: DESCRIPTION OF PRdPOSED WORKS(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': — — - i eta'✓
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building 00 I. Building Permit Fee:$ -Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S Sd . UC) Cl Total Project Costa(Item 6)x multiplier x
3. Plumbing S . 00 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. ,Mechanical (Fire S Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 2)oov e' p paid in Full 0 Outstanding Balance Due:_ _
r r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction/Supervisor License(CSL) Q16�3
�) r b� �2�r�fs�flYi- License Number Expiration Date
Name o(CSL II Ider
1 3 � e 6 �c �� List CSL I)pe(sce below)
No.and Street Ty Description
w �n/1 � /5��� G U Unrestricted(Buildings u to 35,000 cu. 11.)
l� , ll Q Restricted 1&21'mnil Dwellin
C'ilyl1liwn.Stale,"/.IP M Mason
3iw
5 RC Rootin Coverin
tr WS Window and Sidin
qe� �/ SF Solid Fuel Burning Appliances
'JJ ref Lv1;40, 20N.n/F� 1 Insulation
T'cic hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration/Number Expiration DI
HIC'Compan Name or I IIC Registrant Name
1 � LP ( C tti S qt—WlA")
No mid Street q
3T'5 V t C h �— )1 — !n-3S6-00/ Email address
City/Town, ZIP 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
(/1 �_ / *n^ I
1, as Owner of the subject property,hereby authorize h,,
to act on my behalf,in all matters relative to work authorized by this bu ing permit application.
ati ' �/T
Pont Gner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and pepalties of perjury that all of the information
contai d in this application s true and accurate to the best of may knowledge and understanding. .
��n��,u
Pnnl Owner's or Aul o izeAgent's Name(Electronic Signature) Dale
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 riot 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
oca Information on the Construction Supervisor License can be found at fait iv.nmss,goWJps
?. When substantial work is planned, provide the information below:
Total Floor area(sq. ft.) (including garage, finished basementlattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
?lumber of fireplaces Number of bedrooms
Number of bathrooms Number of Iialflbatlis _
Type of heating system _ Number of decks/porches
'type of cooling system Enclosed Open
3. "rotal Project Square Footage"may be substituted for,focal Project Cost"
FREDERICK E. LEVASSE
UR JR DBA
TURN KEY CONSTRUCTION . 1148
38 JEWE17 ST
GEORGETOWN,MA 01833
DATE -nl9V ;2?V4:Ro11 53-7054/21 13
PAY 08
TO
THE - s
ORDER OFc,
ye'i
DOLLARS
Bank
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