78 BEAVER ST - BPA-14-1408 RENOVATE TOWNHOUSE, U2 V, C_CE: NDC25 IIJ(UM '
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building 1 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: Date A lied: Z S
L
Building Official(Print Name) Signature Dale
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Alp --
1.1 a Is this an accepted street?yes_t/_ _ no Map Number Parcel number
1.3 "Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Ilse Lot Area(sq fl) I rontage(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 System:
Public Private❑ Zone: _ Outside Flood Zone'! Municipal�n site disposal systern ❑
ELF Check if yes[]
f SECTION 2: PROPERTY OWNERSIIIPr
2.1 Owners of Record: ,
�o —r AK ;��t�_— h l2
Name(Print ZLl City.Stine.Z '
o.unJ Strcet ST M Telephone Finail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Fsisting Building Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:_
Brief Description of Proposed work'':_QFA/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item *1d Official Use Only
I. Building I. Building Permit Fee: $ Indicate how fee is determinedo. Electrical ❑Standard City/Town Application Fee
❑"total Project Cost(Item 6)s multiplierx
3. Plumbing Other Fees: $4. Mechanical (IIVAC) List:
5. �Mechanical (Fire -- —_
Suppression) $ Total All Fees: $
6. Total Pro ect Cost: $ Check No. Check Amount: Cash Amount:
j ^
f700. ❑ Paid in Full ❑ Outstanding Balance Due:
re r-,[ lS(
V ll�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
063 o,5-9 11t.aohn D(- 7- t" License Number Expiration Date
Namc of CSL 1-[older
List CSL'rype(see below) (J
rl7 5r5N!Erb-R t)[ L, O
No.and Street Type Description
�[ U Unrestricted(Buildin s u to 35,000 cu. ft.)
`r)wt y � G� R Restricted 1&2 FamilyDwelling
City/rown,State, It,
M Masonry
RC Roofing Covering
WS Window and Siding
¢ .J�pq)OeoGk S3 � SF Solid Fuel Burning Appliances
9 7a' S.? d(]'MCSISa ,{- 1 Insulation
'rele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
, el w -) b nGk ��8 ya3
fIIC /jtnuioo Number Expiration Date
I11C(:^mpany Name or I IIC 12egistrant Name
77 600 i to if j> (,-O
No.and Street Email address
S3�c�Ec�Y Mfa c�10.�4 �j7sr F�7 & s z �or.�cw�� . &vE-It
City/Town,State,ZIP 'I'ele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(tNI.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...........9-1'
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Own of he sub' c ,hereby authorize ,Ohfl 3At� �� ,
to ac y hal' ters el five to work authorized by this building permit application.
rint( er's Name �lec onic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Aentmy m I I hereby attest under the pains and penalties of perjury that all ofthe information
his c o is ue and accurate to the best of my knowledge and understanding.. ``— O Opts tN c r A ar zed Agent's 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(HIT) Program), will not have access to the arbitration
program or guaranty find under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass-gov/ow Information on the Construction Supervisor License can be found at www.nmss.gov/dns
2. When substantial work is planned,provide the information below:
Total Floor area(sq. 11.) ��__�y (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) _3�� �_,__ Habitable room count
Number of fireplaces / Number of bedrooms
Number of bathrooms Nit mberofhaIf/baths _ 0
"Type of heating system_-_ -----
_—/44.—y9t_;r-- Number ofdccks/porches_ Q
Type of cooling system___A-X0�_t_— Enclosed —Ie�---Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'