79 BEAVER ST - BPA-14-1951 WINDOWS e �
The Commonwealth of Massachusetts INSPEC ION4TS'WICE
Board of Building Regulations and Standards q SALEM/ Massachusetts State Building Code, 780 CMR 1014 OE R?qe`Al.,`F�/�Y I
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 lied: Cie° iy
aq i
Building Otlicial(Print Name). . Signature- . . Date
SECTION 1:SITE INFORNIATION
1.1 Propeyrty�A7ddress: 1.2 Assessors Map&Parcel Numbers
�L '/�S Ae f
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sy It)
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.do,§Sd) t.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2: PROPERTY OWNERSHIP!
2.1 rvnert of cord: ti-/A 1 70
�hme(PrinQ / City,"itale,zip
79 �zm� t _�y hr> Fyn-�ENB u eL . i9y�srC�u. 1 e:y
No.mid Street Telephone Em it Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction O Existing Building Owner-Occupied Repairs(s) Ahemtion(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work=:
fcC.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
S I. Building Permit Fee:$ indicate how fee is determined:
I. Building
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costs(item 6)x multiplier x
3. Plumbing S 1 (,other Fees: .S
d.XIcclutnical (hIVAC) S List:
5.iMechanical (Fire S Total All Fees:S
Su ression)
_ Check No. Check Amount: Cash Amount:
6. T'utal Project Cost: S yJ75' 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /0%OBO 0 /0
License Number E.e iratton Date
Name of CSL Holder List CSL Type(see below)
T Description
N�Strect .
Unrestricted(Buildings u i to 35,000 cu. It.
7l Q/94,/ U— Restricted 1&2 R tinily Dwelling
C-ityffu0n,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
e-e I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement
nt Contractor(HIC) kg73 r,7 W is
n T r HIC Registration Number Esptm ton Date
HIC CuHIC t�r HIC R5 is nt Name
Email address
No. and Street
hvlr i !A /�
Cit /To n,State,ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.QL:c. I52.§ 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 A PPLIES`FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
7'
Print Owner's or Authorized Agent's Name�Fikt.tronie Signunlw 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(HIC) Program), will nor have access to the arbitration
program or guaranty fund under NI.G.L.c. Id2A.Other important information on the HIC Program can be found at
w-ww.mass. ,ov!ocn Information on the Construction Supervisor License can be round at www.jn,. ,ov'dL.s
2. When substantial work is planned,provide the information below:
-total fluor area(sq. R.) '� ,(including garage, finished basemendattics,decks or porch)
Gross living area(sq. 11.) 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
1. "I'otal Project Square Footage"may be substituted fur rutal Project Cost"