17 BEAVER ST - BPA-13-1029 SOLAR THERMAC 7
l�
ra The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
1 Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tsvo-Family Divelling
This Sect onPorOfficial Use Only. '
Building Permit Number:-. Date hed%.
It ��
wilding Official(Print Name) ' . ?.: $ignat. a„:- Onte
SECTION I:SITE'INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
J�'n- S"/
L 1 a (s t is 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(tt)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§14) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public Private❑ — Check if MunicipaWon site disposal system ❑
$RCTIONZc, PROPERTlf'OWNERSftn1+ _
2.1 Owgqert of Record:
Name(Print) City,State,ZIP
ppZ L1 ✓G�z- S`1
No.and Set Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKI(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work: L 4,4-1
SECTION 4: ESTINIUTED CONSTRUCTION COSTS-
(rem
Estimated Costs:
Ofticlal Use Only-..,
Labor and i✓faterisls
1. Building S 1..Building Permit Fee:$_ ' rntiicate how fee is determined:
2. Electrical $ ❑Standard,.Citya,6wn Application Fee.
❑Total Project Cost(Item 6)x multiplier. x
3. Plumbing S 2. OtherFtes:'S
1. Mechanical (I(V.%C) S List:
. Mechanical (Fire. S
Su ressiwr) _ Iota[All F'ees:.'S_
/ -- Cheek No. Check Auwunt: cosh AutounC
1'utal Project Co.it: S t0./ ❑000, ,
f I ail in Full Cl Outstandifig 13a1a1 Ice I)ue:
SEC'rIOtN 5: CONSTitucrIOYSERVIC6S
5.1 Cottstruetion Supervisor Liccuse(CSL) = q j
License Number — Expiration Date
Name oofo r CS�LL I[older , List CSL Type(sea below)
%'3 009(/ � Type Description
Nu. atJ d Street
/ Unrestricted BuilJin s up to3i,000 cu. ft.
�J y lCi7VILJ 1 3 `V A�U It Restricted ISc3 Fa-il Dwcllin
City/rown,State,ZIP t\11 'Mason
RC Ruufin Covcrin
WS Window and Sidin•
SF. Solid Fuel Burning Appliances
Insulation
I'ele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
FI1CRagistWraationNumber pittionDate
I IIC Cumpany Name or 1IIC Re$$F-IiZ llt Name
ggln'8 ,>�;r+�b 6 �CFFf2L"/�/1GGSwfP/�5t,1•. o.yr
No.and Street Email address
City/Town,State, 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: NEA AUTHORIZATION TO BE C01VIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on tn behalf, in all matters relative to work authorized by this building permit application.
/3
Print fner's Name(Electr rate Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
rlByentering my name below, I hereby attest under the pains and penalties of perjury that all of the information
ed in this application is true and accurate to the best of my knowledge and understanding.
wner's or,\uthorizcd A-eut's Name(Elactrunie Signature) Date
NOTES:
I. An Osvner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will trot have acecss to the arbitration
program or guaranty find under M.G.L. c. 142A. Other important information on the 1IIC Program can be found at
wwcv nrts:.euviaca Information on the Construction Supervisor License can be found at tew•tv.mas .•.nyv_�IL
F '!Whe substantial work is planned,provide the information below:
l floor area 0,I. lt.) ____ _(including garage, finished bascrnent/attics,decks or porch)
; iving area(sy. R.) Habitable ruoln count
ber of tireplacc,_ -- Numberofbedromnsberufbathrnonts _ __ Numberofhalubatlts _ __ _of heating syuem _--— - ---_-- Number of decks,'purdtcs .- . .._- _
I)Ile OfCo,din" syacnt __..— -- Enclosed
I. A ot.tl I'n q,a Syu.uC Pn, rigr"m.w hr aib;tina: l f,v I' ,t.i I'rujtd l', <t"