18 BELLEAU RD - BPA-15-261 ROOF The Commonwealth of Massachusetts RE EIV ���
Board of Building Regulations and Standards INSPECTi NAB tsg�GES
\ Massachusetts State Building Code, 780 CMR Revised Mar 2011
g Building Permit Application To Construct, Repair, Renovate Or DetplKOR g A 1 5l
N1 One-or Two-Family Dwelling
This Section For Official Use Only
1 Building Permit Number: Date Applied: I I I
''I-S' IS
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
(mil 1.1 Op7erty Address: 1.2 Assessors Map&Parcel Numbers
1.1 a 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(ft)
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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner[of R ord:
7LIV ce ��C &\ey), AAA a\C1
Name(Print) City,State,ZIP
I �3e\VAL) Sta g7r-'7111-003
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) El` Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work : 5°rt N p a-ce<-e—c oA �(16mr
I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ lL,y3 1. 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 $ 2. Other Fees: $
4.Mechanical (FIVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ /�p� �/3 c/ ❑Paid in Full ❑Outstanding Balance Due:
�A1u `R'�17Qw`i
Iu PP L I iz:o
SECTION 5: E CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS ApIlf
Ak-Ar� License Number
Expiration Date
Name of CSL Holder
List CSL Type(see below) U '
)F ke�-e\\ o
No. �(�G and Street
Street Type Description
AN �l U Unrestricted(Buildings u to 35,000 cu.ft.
.). /i City/Town,State,ZIP _ R Restricted 1&2 FamilyDwelling
M Mason
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
S0�z�O—o($1, 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I I ?- I� 3//e/o
`Ox" C< *\��� KQ'�okN t� Pbw HIC RegistrationNumber Expiration Date
r�IC Company Name or HIC Registrant Name
6\ Sec,. Or - 'Dr.
No.and Street Email address
C�tel\ef 1 1G6(� GIf>fr14 Soso
Ci /Town,State,ZIP Telephone
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 .......... 17 No...........❑
SECTION 7a: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 matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By en m y e below,I hereby attest under the pains and penalties of perjury that all of the information
conta ed ' is pplication is true and accurate to the best of my knowledge and understanding.
y-a-1,-
Print 0 s r Au rized Agent's Name(Electronic Signature) 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 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.tzov/dam
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 halfibaths
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" '