53 BELLEVIEW AVE - BP APP 09-575 ROOFING The Commonwealth of
t. MassachusettsTO"as City of Peabody
State Board of Building ® Office of the Inspector of Buildings
Regulations and Standards 24 Lowell Street
Massachusetts State Building Peabody,MA 01960
p Code 'h.,E '°� Tel: (987)535-5786
_ 780 CMR
\ ' APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
This Section For Official Use Only
Building Permit Number: ate s
Signature:
Building Commissioner/Inspector of Buil 'ng Date
SECTION 1—SITE INFORMATION
1.1 Property Add 1.2 Assessors Map&Parcel Number r/e�s :,�
Map Number 'arHi Number t
1.3 Zoning Information: 1.4 Property Dimensions: ,j ( i
Zoning District Property Use Lot Area(sf) Fro'til e-.ft
Building Setbacks R
Frmn Yard Side Yards .ear'Y' M +
Required I Providedt1.7FIoodZonc
aired / rovided Re ufSed'. i I Provided
1.6 Water Supply(M.G.L.c.40.§54) nfoj anon: ti8 SewageDtspo�aFstetojPublic ❑ Private❑ utside Flood, Mogt5+pa1 C➢ O'site disposal system ❑
r i
SECTION 2 ' PROPERTY-OWNERSHIP/AUTHORIZED AGENT ` ++
2.1 Owner of Record: ) /
Name riAddress s yt
Ill lti i —�/
i 11
Si nat a r' 1 Tele'hone
2.2 Au orize Aged[; /A Y ' "'
Name(print) j ! ' -' Address
Si nature Telephone
� + ; t
SECTION 3—CONSTRUCTION SERVICES FOR PROJECTS LESS.THAN 35,000 CUBIC FEET OF
.ENCLOSED SPACE ,
Licensed Constructio luj S�upf isor: _ ` Not Applicable❑
0 !'I' !2 co e� ✓ �—
Name(print)
Lice se f4umber
Address /
Expiration Date
Signature
Registered Home Improvement ontrac[ J Not Applicable❑
G .G,• // C
Company Name
License Number
Address
Expiration Date
Signature V Telephone
i
SECTION 4-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.... I
SECTION 6 DESCRIPTION OF PROPOSED WORK(check all applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alteration ❑ 1 Addition = ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify:
Proposed Use: Single Family Dwelling C Two-Family Dwelling ❑
Brief Description of Proposed Work. /
t (L f
SECTION 6-ESTIMATED CONSTRUCTION COSTS All Building,Wiring,Plumbing,Gas,Fire Suppression and Alarm Fees
Item Estimated Cost(Dollars)to be will be paid by the general contractor or owner at time of issuance.
completed by permit applicant --Official Use Only,
1.Building (a)Building Permit Fee Multiplier.
z.Electrical ,,(b)Estimated Total Cost of
Construction from
3.Plumbing .Building Permit Fee'
4.Fire Protection (a)x(b)
5.Mechanical =Check Number °
6.Total= 1+2+3+4+5 U(7tX'
r-SECTION 10a OWNER AUTHORIZATION-:TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT `s
[!_� as Owner of the subject property hereby
Authorize / / f C/l !a•A/ to act on my behalf, all matters relative to
work authoriz by this building it applicatio
Signature o Ow er Date
'SECTION 10 OWIqERJAUTHORIZED AGENT DECLARATION
I, '6 k1& as Owner/Authorized Agent hereby declare that the statements and
information on the foregoing dpplication are true and accurate,to the best of my knowledge and belief
Signed under the pain and penaIt es etZZ per'u
/r - r
Print N$ E
Signature of Owner/Agent Date
FEE BREAKDOWN OFFICIAL USE ONLY Notes: ,
Estimated Cost
ITEM MULTIPLIER FEE
Building
Electrical
Plumbing
Gas
Total Permit Fee -
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
s Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information c / Please Print Legibly
Name (Business/Organization/Individuual): - i 6 d/
Address: ^/? 1 (fi l 14a V
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
6. ❑ New construction
employees(full and/or part! have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
o workers' comp insurance i 5. ElWe are a corporation and its
10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I E] Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
[contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
information.
Insurance Company Name: i p /
Policy#or Self-ins. Lic. #: zy —6�— / D Expiration Date: J ff e
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify ypder the pains rdpeQhies p fury that the information provided above is trueland correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#: