5 BECKET ST - BPA-14-1398 RENOVATIONS INT/EXT 114- 15jj � Kzit �o 5� u
The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building 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: Date4plied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1a 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(it)
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 CY Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal Ia'On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of Record*
i/� /may Z/�+ G �Lc tr O 19 ?o
Name(Print) City,State,ZIP
I'�Pthet{ � r�f (9r� �g9-7S�lU
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) FtiSnNG
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Er Alterations ❑ Addition ❑ 7tN i�
g g P ( ) aEorator,.
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: e— <
Brief Description of Proposed Work': -L i' &J 1 n. J
W e4F c E
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CTION 4:ESTIMATED CONSTRUCTION COSTS
r Estimated Costs: Official Use Only
(Labor and Materials
uilding $ 6 Q 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ D ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier_x
3.Plumbing $ I11-15on 2. Other Fees:
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Q Check No. Check Amount: Cash Amount:
6.Total Project Cost: $V 2150 p ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
h h � License Number Expiration Date
Name of CSL Holder // .1
,�JVo r—A �/ r—�'f Lis[CSL Type(see below) y
No.and Street MDiDemolition
Description
V/f Le � a 01970 tricted Buildin s u to 35,000 cu.ft.
cted 1&2 Famil Dwellin
C:ty/I'own,Slate,ZIP
Coverin
7�r�9uncQhTle�? TO/2wanasidn
uel Burning Appliances
9 78 �8—CD 0 4 5 hLT% ve F7�' /t /2 7- tion
=Home
Email address Demolition
red Home Improvemen�ntractor(HIC) 7�j SR"" �'v h HIC Registration Number Expirat on Date
Name or HIC Regi [rant Name
rJ✓*t C�r �40j". r2rsc.'TUa— 'I3T
t Email address
ivl /Y//,' 01cl? C) vtrlLon . Ttate,ZIP Tele hone
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 .......... a No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 4o J /1 yyt L�
to act on my behalf,in all matters relative to work authorized by this building permit application.
�(G® CAt��ACeHe E t5M wwo t4A9PU2 15010
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGE=DECLARATIONBy entering my name below,I hereby attest under the pains and penalties oformationcontained in this application is true and accurate to the best of my knowledL10 GA< bAGNER Ae PoPc LILo t{RRPU9t �lNPrint Owner's or Authorized Agent's Name(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(HIC)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.gov'oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"
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