1 BELLEAU RD - B-15-35 PERMIT & APP RENO 1 & 2 BATH l �S rE
The Commonwealth of Massachusetts REC
} Board of Building Regulations and Standard�SPECTIOMassachusetts State Building Code, 780 CM Building Permit Application To Construct, Repair, Renovate Q6003W
One-or Tivo-Frrrnily Dwelling `g'J Jn"
1 n This Section For Official Use Only
1y ) Building Permit Number. Date Applied:
1 �S
1 Building Official(Print Name). Signature- ate
SECTION t:SITE INFOR.4(ATION
L� Progerty Address: �� — 1.2 Assessors Mop Sr Parcel Numbers
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1.1 a Is this an acce ted streetl yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Propose)Use Lot Area(sq ft) Frontage(Il)
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:
Zone: Outside Flood Zone?
Public❑ Private C3 — Check if es❑ Municipal❑ Onsite disposal system ❑
SECTION2: PROPERTY OWNERSHIP'`
2.1 Owner of Record: -� d
�Tomes a J Oren (reor4R_ SoIeK)l
e(Print) City,State,ZIP
/ Qe /lean Rio qV - 910-/sae sc�ce-1vmr� o� yahoo<coM
No.and Street Telephone Email Address Ll
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Gf Repairs(s) ❑ 1 Altewtion(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units i Other ❑ Specify:
Brief Description of Proposed Work':
rcooya e- rTTF rav✓Y).r � lst /vv✓'� a{- o"tn ver
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 0 0 U I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S ] 0 o D �?(,Ether Fees: S
4. Mechanical (HVAC) S List:
3. Mechanical (Fire total All Fees:S
Su ression)
Check No._Check Amount: Cult Amount:_
6. Total Project Cost: .S 5 i U 00 ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holderi List CSL Type(see below)
TypeDescription
No.;rad Street
U UnrestricledDuildin s u to 35,000 cu. Il.)
R Restricted 1&2Famt1 Dwellin
Cily/rown,Slate,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
IInsulatton
Tele hone Entail address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
111C Company Name or 111C Registrant Name
No.and Street Email address
Cit /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.§ 2SC(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 ..........17 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
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.
J 6L0)fJ 4- J OG ✓t GC0 Z
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Print Owner's or Authorized Agent's Name(C•Iecuon Sigt t ) Date
TES:
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(IIIC) Program),will Liar have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www mass 1ov:'oca Information on the Construction Supervisor License can be found at wwtv.ntas. o�!dys
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. tl.) 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
i. "Total Project Square Footage"may be substituted fitr"'rota) Project Cost"
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Commonwealth of Massachusetts
x City of Salem
v« 'c 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595x5641
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Return card to Building Division for Certificate of Occupancy ,
Permit No. B-15-35 FEE PAID: $105.00 BUILD
DATE ISSUED: 1/12/2015
This certifies that GEORGE JOAN C GEORGE JAMES NICKOLAS
has permission to erect, alter, or demolish a building 1.BELLEAU ROAD Map/Lot: 320285-0
as follows: Renovation RENOVATE FIRSTN&SECOND FLOOR BATHROOMS
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Contractor Name:
!341k k A
DBA: l` 1l�� I
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Contractor License No: �;�I
1/12/2015
lr - Building Official �� Of Date
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This permit shall be deemed abandoned and invalid unless the work authorized by this permits commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request
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All work authorized by this permit shall conform to the approved application and the approved construction documents for whichthis permit has been granted.
All construction,alterations and changes of use of any budding and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. 'F,IhNz;' ..
The Certificate of Occupancy will not be issued until all;applicable signatures by the Building and Fire Officials are provided on this'permit.
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L.I IC $/: Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A).
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Restrictions: +r i � "
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Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.