26 BELLEAU RD - BPA-11=392 WHEELCHAIR RAMP i The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
J Massachusetts State Building Cute, 780 CMR, 7"cdition OF SALEM
Rrvisrv/Jurnnvr
Building Permit Application To Construct, Repair, Ronovat Ur Dcmulish a /. :(RAV
One-or rim-Family Dwelling
This Section FaF101Mciai Use qtfly
Building Permit Number-
Oat Applied
( i
Signature: I /�' do) /�
gs coBudding Commissioner/Inspector nl in
SECTION 1:SITE oRMATION
11.71/Props Address I. son Map J Parcel Nembers
oc.[, / CD j
I.la Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning information: 1.4 Property Dhneaslons:
Zuning District Proposed Use Lot Ares(sit 11) Frontage(tl)
1.5 Building Setbacks(It)
From Yard Site Yards Rest Vent
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§Sec) 1.7 Flood Zone Information: I.11 Sewage Disposal System:
Public O Private O ZuM. — one Clteck iif Floodde OZ7 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
>;-I Owoer'ot
Name IPrim) Address for Service:
t
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check oil that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) O Alteration(s).Cl Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Speci :
Beef Description of Propo Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OIIlclal Use Only
Labor and Materials
1. Building S I. Building Permit Fee: f Indicate how fee is determined:
2. Electrical f ❑Standard City/Town Application Fee
❑Torok Project Cost(Item 6).a multiplier, x
J. Plumbing S L2.i Other Fes: S %77j q
1. Mechanical 1)IVAC) S List:
3. Mechanical (Fire
Suppression) S Total All Fees:S
6. Total Project Cost: S / /}—�o Check No._Check Amount: Cash Amount:
C t�v — O Paid in full ❑Outstanding Balance Out:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction supervisor(CSL) __ � �d
IiC Ifi1Wn JIC
i.l�rflee Numlfer
NJrr�,ncCSL•I I.it CSL type!see below) (,L
( I)curi ion
Add sit /�` c U llnrestricled to 33.000 Cu.Ft.
6 Ec y J R Rcslricted l/2 f3mily thsellin
Si ure M M Only
t../ RC Residential Rmfina Coverings
• �/ / WS Residential Window and Sidin
7 -2 y y 7(p y SF Residemial Solid Fuel Bumin A liame Iromllatiun
D Railkntid Demolilian
!, istered almpro emeat otnctor(NtC)
Reglstratlan Number
,Nrl y Name or I IC i i Name
Addle ( r C` Ea ration
ire ' rlepMrns /
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. ISi 12SC(6))
Worker 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 ..........O No...........
SECTION 7s:OWNER AUTHORIZATION TO BE C11 OMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1' as Owner of the subject property hereby
to act on my behalf,in all matte
authorize r relative to work authorized by this building permit application.
Si ore of Owner Dote
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name�-
Siv wtur of(hvner a ut Orirsd Agent 1e
Si under the sins and periallies of •u
nofE
I. An Owner who obtains a building permit t his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will lg have access to the arbitration
program or guaranty fund under M.G.L. c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.RS.respectively.
21, When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basemenVanics,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
T)pe of cooling system Enclosed ()pen
). "Total Project 5yuare Footage"maybe substituted fb("Tidal Pmject Cost"