0001A BELLEAU ROAD - BPA-97-13 4
a --- I'he C'onttnontvcallh of Massachusetts
Ilimrd of Building Regulations and Standards CI I'1.OF
tr ;•( Msssaclnlsctts State Building CoJI C'NIR SALEM
Building Permit Application To Construct. Repair. Renovate Or Demolish a HI It'll :W1
Ohre-or Tun•Piunih' D d lhnk,
This Section For 017 eial Use Onl
Building Permit Number: _ Date pplied:
Mudding Uliicial(Print N;une) Signature Dale
SECTION I:SITE INFORMATION
X1.1 P open Address: 1.2 Assessors.t lap di Parcel Numbers
L la Is this an acce led street? •eT— Map Nunsher 1'urccl Nunsher
1.3 Zoning Information- 1.4 Property Dimensions:
Lining District Proposed lJst Lot Area(sq A) Frontage III)
1.5 Bullding Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Pruvided
1.6 Water Supply:(M.G.1.c.40.§Sa) 1.7 Flood Zone Information. 1.3 SewaQe Disposal System.
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if ts❑ Municipai G On site disposal s)stem ❑
2.1 Ownerr of Record•
SECTION I: PROPERTY OWNERSHIP'
n�.accJa'c �S�
unairrum 1.11I
/ho sS
u l>,slate,
Nu.and Street r relephune III Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Osvner•Occupied ❑ Repoirs(s) ❑ Alteratlon(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg,p Number of Unib_ Other ❑ Specify:
Brief Description of Proposed Work-:
/ �rP/6�i � Spa t`r fhr sr � 3 F ry r
v
SECTION J: ESTIMATED CONSTRUCTION COSTS
hells Estimated Costs: Ofliclal Use Only I labor and.Materials) y
I. Building S I. Building permit Fee: S htdicate how I'te is determined:
'. Elcorical S ❑Standard Ciry'Totsn Application Fee
I �. I'IumMng S O Tutal Project Cost'(Item,6)x multiplier
_. Other Fees: S
J. \1"Ilallw'll ill\' \(') S List:
Fcet: S_
n 1'ulal Prnject Cust: 53®lJ Check No. _ -_('lleek:\nunml: . __.._..l',�sh \mrnmt:
.5 !> 0Paid in Full l7 Uuttt:mJing Bal.ulce Due:
sk:cHON 5: ('ONSI'llUcrION SY.RN'I('F.';
0,1 License(('Si,)
Construction Supenisor Li
--- —*-- i Npiralloo Mile
occo.,c Nwithcr
lie(i"
L'sl, I I,, let I I't 01.
PC Description
It
M ;11011
..... KC Rmili" L'oserin
,A�S— windim Aid Sido
SF Solid Fuel IltimillillAppliances
I Insulation
Email 2 DemolitionNic 111111te rJ
ii,;l Registered llume Improvement Contractor(111C)
—F�,pirtuwn Due
III(:Itcliirgion Nurnier
I lic compin) Name or I IIC Itcgistrant Njout
Email address
Q. Aid Street
relephone
Ci own.State ZIP ON INSURANCE AFFIDAVIT(M.G.L.c. 1s3.I 25C(6))
SECTION Gi WORKERS'COMPENSATION
is�M�davit�mustbe completed and submitted with this application. Failure to provide
Workers Compensation Insurance
this affidavit will result in the denial of the issuance or the building permit.
Signed Affidavit Attached? yes ..........Cl No...........
SECTION ION 7e- OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S ACENT OR CONTRACTOR APPLIES FOR BUILDING PE111,11,111T
1, as owner or the subject Property,hereby authorize permit application.
to act on my behalf,in all matters relative to work authorized by this building p
Mike
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjurythat all of the information
I reed this applica
coa!0on is true and accurate to the best of my knowledge and understanding.
l Q
ZAY, DJIc
Kim (FIccuonic
VOTES:
is.her own%vork,or an owner who hires an unregistered cuntractor
I An 0,mci who oblams a building permit to a lout registered in the Hume Improvement Contractor I H 10 Program).will no have have access to the arbitration
program
I or guar nt) load under M.G.L.v. 14-1.A. Other important information on the HIC Program can be round at
Construction Supervisor License can be found at kt%%
\%\%,% 111.11, .•' I hil'ormation on the
Wien substantial work is planned.provide the hifurinnflun below:
I including garage. finished basement.attics,decks kit porch)
foDl our area IS+ Habitable room count . .. . . .
n g area I s4. III \,,p,her ot'liccirooms
Number ot'half hallos
\,nuberol'ballif0k)"'i Njilliber porOws
I I'licloNcd .01'cn
i I,o,il Prolco silume Foolacc I'k: 'uhlillacd lkir I"It'll Projcct CoNi"