19 BELLEAU RD - BPA-13-384 GEN. RPRS . sy 2 !) .
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
�r 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
B
uild4 Permit Nu er. p
Building Otlicial(Print Name)/ Si�at. Date
SECTION I SITE ii" IATION
LI PGrDpe y Address: C 1.2 Assessors Map&Parcel Numbers
XI I 9'e IIeL.Uo ✓G.�t^1
I.In 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 tt) Frontage(R)
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 ifyes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of R cord:
CinA7 l oar` a�lfi SCAM D/9'7 o
me(Print) ° City,State,ZIP
ti gzVee t,, ed S,(_,,t lk,
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Worrk2: r, P, n,�, U_J 7 of a r
fo 1l v< In N ✓ tl
(3 Z_ i«x &za 02&H Ljl t.,� ;•d�_
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Estimated Costs:
Item Official Use Only
Labor and Materials
I. Building $ '3 6 D O 1. Building Permit Fee:$ Indicate how feeis determined:
�. Electrical $ US tandard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
. Plumbing $ 2. Other Fees:
4 M (H
. Mechanical VAC) L �$ List:.. � b
5. Mechanical (Fire $ —
Suppression) Total All Fees:S
Y Check No._Check Amount: Cash Amount:
'\ 6. Total Project Cost: $ '3 Uv 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1 A- �s-68�o53 2 i zo/y
License Number E.epiration ate
Name of CSL Ifolder
/V List CSL Type(see below)
Nu.and Street / Type Description
n//./ U Unrestricted
.Buildin sti to 35,000 cu. It.)
\(M rno h� �3 p � � R Restricted I&2 Family Dwelling
City/Town,State,ZIP M IMasonry
RC Roofing Covering
WS Window and Siding
� SF Solid Fuel Burning Appliances
�gJ_1SY 93� �IP,*e-'.tan++-A[fi'Wi pl� I Insulation
Telephone / Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
D N /y6319
!6` y v„ t'E HIC Registration Number E,piration Date
FIIC Company Namee o or HIC Registrant Name -
,;/
No. $ 54,
and Stree mGn
Ci /Town,State,ZIP C75077 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 ..........❑ 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) 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 in ap licat�s-"e and a rate to the best of my knowledge and understanding.
Print Owner's or Authorized 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
svww.mass.eov'oea Information on the Construction Supervisor License can be found at www.mass.,'ov/dPs
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/atties,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
'rypeof cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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