64 BEAVER ST - BPA-14-1315 SIDINGT Tf3- Itt-� 3is q (:) $ 15
l The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR RECE V SALEM
IlASPEThOtd lis?o//
Building Permit Application To Construct,Repair,Renovate Or emo is a
One-or Two-Family Dwelling
This Section For Official Use On
Building Permit Number: Date Applied:
T )
Building Official(Print Name) Signaturel W Date
SECTION 1:SITE INFORMATION
1.1 Propperty Address: 1.2 Assessors Map&Parcel Numbers
toy 151itr2 5`l7'1Li
L l 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 ft) Frontage(ft)
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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
'111 2uSCt4E� Sf�y✓! all Ol q -7o
Name(Print) City,State,ZIP
0 6iV'%M .5r, g7t-3%`1-430ti
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(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 Work2: [RtoggcF eZWjVV(- f /1 19ig7K %Uoi CAM VLCE d1I�311fiL�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ Dvb 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ �00 ❑ Standard City/Town Application Fee
❑Total Project Cose(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ a( (id ❑Paid in Full ❑Outstanding Balance Due:
SE�)t� -M V\ ' 6 -
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 6rOK 3 (S 26N,
_ STi✓ye ouy&q-( License Number Expiration Date
.t Name of CSL Holder
33� /w&c 5,( List CSL Type(see below)
No.and Street Type Description
Unrestricted(Buildings up to 35,000 cu.ft.
Ntuv to I7r q l Gl9aj R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
-91 F-g2970 57 K-3Y 3Y e C0y1ft,&07 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 7(Mc( 30 6l 1p
1�5TlL 6*5T&&-11T0L) HIC Registration Number Axpi6tion Date
HIC Company Name or HIC Registrant Name
L3�t E< S-1K3C/3y�Cr�AT�,crtin
No.and Street Email address -
9 W YLS 1nA GiTk3 76
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..........)d No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRAC OR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize It V " 3 Y.Uai1r
to act 91 my behalf,in all m tters relative to work autho ' by this b i ding permit app ' tion.
=
Prin ner's Name(El n nic Signature) Date
TION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby aftte under the pains and penalties of perjury that all of the information
contained in this application is true to to the best of my knowledge and understanding.
sT� � �y
Print Owner's or Authorized Agents erne(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(1-IIC)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
www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"