28 BECKFORD ST - BPA-12-641 RENOVATE KITCHEN o:� ��aa. - ice
III � �, l he C'onnnomsr:dth of Massaehuseus - .
yl i� Board of Building Regulations and Standards Cl IT OF
Massachusetts Statc Building Code, 780 C'NIR SALEM
U 'L,•• Nrrisrd Jhu•'0//
Building Permit Application To Construct, Repair, Renovate Or •nwlis a
One-or Tmv-Fumilt•Du eRrm j+
This Section For Olrcial Use Onl
Building Permit Number. Date, pplicd:
Building Oliicial(Print Nwnc) S tatu Date
SECTION I: SITE INFOR31AMON
I.Prrooperty Address: 1.2 Assessors blap h Parcel Numbers
1 Cgecn¢ ,-o S7"
I.la Is this an acce ted stree0yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
" Zoning District Pn,pascJ(!se Lot Area Isit It Fmmage
(II)
1.5 Building Setbacks(R)
_ Front Yard
Site Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.$Sewage Disposal System:
Public❑ Private❑ Zane: _ Outside Flood Zone? Municipal❑ On site disposal Check if es❑ P s stem D
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Name
e(9((Print) C ity.State,l.IP
' an �3fCKl�v2/'� S'r 7 Y'Y-7Eo 9
No.and Street Em
hone
D ail AJdnss
Tele
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) (3 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=:
Si?iHQ l szy'v7— r 1761 —
��F n
sarvr,
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
I Labor m,d.Materials) Official Use Only
1. Building S w 6�-C)d 1. Building Permit Fee: f Indicate how fee is determined:
2. Fleclrical S ;__, ❑Standard CityrTown Application Fee
❑Total Project Cost'(Item 6)x multiplier
i. Plumbing r. 2. Other Fees: S -
a. \leihanic,d III\ 1('1 S List: _
5. \Iech;utical (Fire —
---
tiutrressionl rtmal .\It Fees: S_
n. Total Project Cost S Check No. _ —('heck Amount: _ -- Cash \nunurt:
❑ Paid in Full ❑Outstanding Ilalmtce Due:
SEC"1'ION S: CONS'I-RUC'rmsl SERVIl' ES
5.1 Construction Supervisor License(('St.) ClL3 /_ /d ZS /2
-- I icensc Nlnnhcr rspi alum 1hp,
\;unc of C'sl. Holder
I ist l'sl.
U
h)pe Dcicripliun
No. and Street
11 1 hlrestricled I Buildings tio nl 15,I100 eu. 111.1
Restricted 1l2 Fanlil Dwellin
Cil\i roan..Slate.Lll' AI Masonry
RC Rtwlin Coverin
1Ps R'indow and Siding
SF solid Fuel Ilurning Appliances
CnD Q ��if/ I Insulwiun
1'ele hmlc Firmiladdrers D Demolition
5.2 Registered Ilona Improvement Contractor(HIC) Z�
e I Z� � S 3
S� 11!1%-L 1IIC'Itcgisuwiun Numhcr Expiration )utc
IIC'Conlpan) N:umc or I IIC Itcgislrunt Name
No. and Struct Email address
CityfTown.State,ZIP rcic hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. IS2.§ 25C(6)) 4
Worker 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 ..........O No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
to act on my behalf,in all platters relative to work authorized by this building permit application.
Print Owner's Nurne(Electronic signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in1*11kapplication is true and accurate to the best of my knowledge and understanding.
Prim Qencr'stur: udul J Agent's Nauw 11.1¢ctrunlc Signature) Dalo
NOTES:
1. An Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC)Program),will rro have access to the arbitration
program or guaranty fund under AI.G.L.c. I42A.Other important information on the HIC Program can be found at
aa,% ma„ Information on the Construction Supervisor License can be found at a>\„ nLin+ z�!A Jp,
2. When substantial\wrk is planned,provide the infurinmiun below•.
rota) Iloor area Isy. R.)_ I including garage, finished basement attics,decks or porch)
(Irons liking area lsy. tl.l Habitable room count
I \lunbcroltireplaces ._. _ \unlherufheJruumi .. . .
\unlher kit'hathrounls - — \'unlbcr kit'Imll'haths
I)pe of healing is stem \umber ol'dccks porches
i
I\lie ofCoollllgi\sicill I�IICIOriII (!pelt
1. I'olal 14ojeet Syuare Footage"m;q he substituted fir-I'oml Project Cost-