4 BELLEVIEW AVE - BUILDING INSPECTION t
ga The Commonwealth of Massachusetts
'n?t Board of Building Regulations and Standards CITY OF
df 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
`?3 Tliis Section For Offibial Use bul .,
Building P,einrtNtunber.:` a,..;" _ ,�
Bwldmg Offiotal(Print Name)
,..... .......r . t,Signature
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
51 Lie//BVi ek/ AV2.
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/0, 000 /00
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 2"' Private❑ Zone: _ Outside Flood Z9neT Check if yes Municipal 0"6n site disposal system ❑
ti;•=au"SECTION,2f'PROPERO TYW)Vg
2.1 Owner'of Record:
AA S l(a cur 3S
No (Print) Q 1/' City,State,ZIP
No.and Street Telephone Email Address
SEG'170N3cDESGItIP1'iON:OFPROPOSED`R'ORK1i checkspthatspply} `" .at,.,..,m„ „?•',s,
New Constmctiono* Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units / I Other ❑ Specify:
Brief Description of Proposed Worle: Ringo_ , A hahrtlorn$ an jd / k ej, Filrcli
raaSt Mtn N ri+ e— YA &A /se y/yr Awom a kid t tearsd ,Qpr an
t
S19MON 4:ESTIMATED COIVSTItT7CTIUN COSTS . ... ' - i r
Item Estimated Costs: - !•�� s` ' I § 4�
i Dfficral Use Only , .
Labor and Materials �l- r "r,,,�',m. :,u.a ; ,,: m.m..s..�.,a .v.3t A.,;,
1.Building $ 1 Burlcoo
dtngPenmitFee $ .11 §'`�='Indicate how fee is detemrmed:,
❑Standard`City/Towo Application Fee Wx h
2.Electrical $ `3 O O ,❑Total Project Cost°(Item 6)x mt� ultiplier at:.5x itt' '� 1
3.Plumbing $ 3, 000 2Othe�PeCs $ ` I? ,§ ;YSti'n,aiv..+;- :-, § a • r � -5.
;l 5
4.Mechanical (HVAC) $ k,w,wu, 't, .,,_r
S.Mechanical (Fire
$
Su reasron �. ,
Check No. Check Amount+ Cash Amount: =
6.Total Project Cost: $ �Y 000 ❑Paid"m Full ❑Outstanding Balance Due
• i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildin s no to 35.000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Memory
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Street Email address
City/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 .......... ❑ 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
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 entering my name below,I 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 my knowledge and understanding.
Jffit.•N-" maerr'4- k e",its, c'krk- /Irl►3
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
www.massgpv/oca Information on the Construction Supervisor License can be found at www!mass.gov/dys
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"
BASEMENT
i
1/2 BATH
LAUNDRY
I
ALL NEW CONSTRUCTION
MECH FAMILY ROOM
ROOM
O
CLOSET
PT-FLOOR
RENOVATION
RENOVATION
BATH
BEDROOM KITCHEN GARAGE
BREEZEWAY
LIVING ROOM
DINING ROOM
2ND FLOOR IRENOVATION
CRAWLSPACE BATH CRAWLSPACE
BEDROOM BEDROOM
CRAWLSPACE