20 BELLEAU RD - BPA-16-1439 ROOF The Commonwealth of Massachusetts
Board of Building Regulations apdSW&'Eds CITY OF
W
Massachusetts State BuildingGFod� C1�l�hJa SALEM
Revised Mar 2011
Building Permit Application To Construe� e�j� R no ate Or Demolish a
One-or Two-Fallf��k'k�ir�� P I: di
t This Section For Official Use Only
Building Permit Number. Date Applied:
p(I� Building Official(Print Name) Signature IZ Date
SECTION 1: SITE INFORMATION
1.1 PProoppert�y Q\\ess: a 1.2 Assessors Map& Parcel Numbers
111 nli aern MR
I.la 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(11)
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?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Cam\ \ r\S S c a w� A a> c�—1
Name(Print) City,State,ZIP
_15 P0.��\e\ eA �1-1-8__y —�-�-�2 iex�rcL C-o1\�v\s
No.and Street Telephone .,mail Address .00VV\,
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ I Number of Units Other Specify: F
Brief Description of Proposed Work': t14
—! 0 2C12 A W � u`\ Via_' ��—Y�o-t��hSr. N.% -e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
I. Building $ 7. S 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ -71 C(-7 S ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Rp
)r�o 1\ A Lp_g\0.�C License Number Expiration Date
Name of CSL Holder
9L
List CSL Type(see below)
-r�bb-e� k c lyre_.
No.and Street T c Description
U Unrestricted(Buildings up to 35.000 Co.ft.)
dC�Y��hesrSl n��� R Restricted )&2 Family Dwelling
City/Town, State,ZIP
M Masonry
RC Roofing Coveting
WS Window and Siding
SF Solid Fuel Burning Appliances
olTk-q22-a�DL{ C�CCAS\le \23C� I nsutation
Telephone Email address �2 D Demolition
5.2 Registered Home Improvement Contractor(HIC) '`tee /^ _
Registration
Cn� Ca at R Date
l8
HIC Registration Number Expiration Dale
HIC Company Name or FIIC Registrant Name
for-, C-urnrv�lr�o�C-1.r- 113E5 �ac�le \23 (�
No.and" xs,r �N 0\9 StreetEmail address 'E-
Ci /Town, Stat�,'ZZIP 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 Issuanc 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
1,as Owner of the subject property,hereby authorize y,. She S\r_ C\e\\ I A C CwS\-\2
to act on my behalf, in all matters relative to work authorized by this building permit ap tp cation.
Print Ow 's Name(Electronic Signature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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 Any knowledge and understanding.
r�s};� Sw�ndelY&Jo I-L
Print Owner's or Authorized Agent's Name(Electr nic 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov.cips
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 half/baths
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"
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