23 BECKET ST - BPA-13-82 INSULATION 7
---- I'he Cbomnumvealth of bfassachusells
Board of Building Regulations and Standards Cl I'1' OF
' 7 Massachusetts State Building Code, 790 C'M1IR SALEM
Building Permit Application To Construct. Repair. Renurte Or Demolish a
One. fir rich-fanidY Dm a'RBr•q
This Section For Official Use Only
Building Permit Number: Date A plied;
hn ing 011ieial(Prim Nmne) Sig,tntu Dale
SECTION I: SITE INFORD TIO
1.1 Pro Nddr�ss: S 1 1.2 Assessors Jlap St .arc Number —
I.1 a Is this an acre ted street? es of Map Number Parcel Nunthcr
I•J Zoning Information: 1•41 Property Dimensions:
Zoning District Proposed Use Lot Ana Isq II) Frontage(11)
1.3 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Pnsvidcd Required Provided
Ld Water Supply:(M.G.L c. Jo,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ zone: _ Outside Flood Zone? Municipal❑ On site disposal s)stem 0
Chackif yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 rt Retard:
No.and Street rclephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alt on(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other pecily:
Brief Description of Proposed Work': s'k is S
vCP
SECTION 4: ESTLNIATED CONSTRUCTION C05TS
ltcnl Estimated Costs: Official Use Only
(Labur and.Materials)
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard CitylTuen Application Fee
2. Iaairical S
(3 Total Project Cuita I Item On multiplier
1. 1'Iuuahing S v. Other Fees: S
J. Mech.utical Ill\ \(•) S List: -
' u uc.....n total All Foes: S_..-_----
('heck No. ( heck :\nnnun: C.nh \m.not.
r. I'Mal Project Cost: 1 0 Raid in Full D OulsLmding llal.tnce Due:
1,
SECTIONS: CONSI'RUc rION SFRVICTS
5.1 ('unstructiun Supen'kur License ICSLI /a_2 51K�
I iccnse Number I'Npire a Da
N.u1 e of l'SI. I IolJer !f•` / /
/r �,/• , IIstCSI. I'1Pelsecbelulkl,__,_�1../_—..._
Deskription
N11. .nIJ Streel
d /� � I 14 cstricrcJ I IhulJin s li ro It,lllltl eu. ILI
Q S• !! �_ �l ._� l-� R eelricled IR2 lautil Dllallin
l'iniloll n.Stale.Lll' ..\I \lasun
IL R,wlin L'ukarin
N'S %indim and Siding
79d (�� I hisul pool Ruining Appliancb
6/Sol d I Insulation
etc bona Pnulil adtiresa D Demolition
5.2 Registered Home Improvement Contractor(HIC) _^A? V /
S��J� - 4
��/ d/✓S� I IIC'Itcgislr;awn Numl+er If cpiruli I IJute
III(Cogg�iQ on) ante or I IIC•Itegimrum Nanw
4f0 /d/Y /Pry
!:mail aJJrcsy
City/Town.State ZIP rcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed d submitted with this application. Failure to provide
this atfidavit will result in the denial of the Issuance of ullding permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPL WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BU IN PERMIT
h as Owner of the subject property,hereby,author a i
to act on my behalf,in all matters relative to work god ooized by II (Iding application.
e q dip SEso2M ) » o � L
Print OkNler'7 Nulne( .Ieetrianic Signature) Date/
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
L
ng my name below, I hereby attest under the pains and penalties of perjury that all of the information
in this application is trueand accurate to the best ofmy knowledge and understandingY1aTI� 7 rne)JNL, �r's ur:\uthorircJ.\gent'i N;une(Plevtronie Signalun) uta
NOTES:
I. An Owner Nebo obtains a building permit to do his her own lkvrk,or an owner who hires an unregistered eowractur
I nut registered in the Hunle Improvement C'untractur(HIC) Program).will nu have access to the arbitration
program or guaranty lund under...M.G.L. c. 112.A. Other important information on the HIC Program ran be Ihund at
111k11 01 "I I Information on the Construction Supervisor License can be found at 11114 In.l.• " 1 JI+�
-. \\'lien substantial+wrk is planned, pru%ide the information bciokv:
total flour area liy. R.1 _ ____„_I including garage, linished basement attics.Jeeks ur ponhl
Clrois liking area 1 iy. 11.1 _.._ ._. ____ . _ ilobitable ruunt count
\unlhcrol'lireplaces \'uulherofbcdrooms - -. ... .
\uulhenrfhathnwnls ._ _. .— -- \umbcrot'hAt'hathi
I\pe of heating i)ilenl \umber o(Jecks, porches
f11`eofCPUIIIIy )aelll I'IIe1o,eJ 1111e11
t
ILII I'n`jed $yIGIrC I'1hll,lge 111;Ik he 111hQlltllUl tUf"111I,11 PfYfeel ('llsl"