10 BENGAL LN - BPA-13-479 RPR FOUNDATION CRACK -4 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR S
sed Mar 2011
�� Building Permit Application To Construct, Repair, Renovate Or Demolis
One- or Two-Family Dwelling
This Section For Off ' e Only ;
Building Permit Number: D pplied:
10
Building Official(Print Name) Si a Date
SECTION 1: ITE RMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
10 Bengal Lena
1.1 a 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 fi) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided RequiredProvided
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 ifyes0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of Record:
Crowninshield Management Peabody, MA 01960
Name(Print) City,State,ZIP
18 Crowninshield Street 978-532-4800 Jfama@crowninshield.com
No.and Street Telephone Email Address _
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building® Owner-Occupied ® Repairs(s) ZI I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
Repair Crack in foundation
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 20,000.00 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑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: $ 20,000.00 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS 71077 7/25/2013
Charles J. Mlnasalll License Number Expiration Date
Name of CSL Holder
9 Epping Ave List CSL Type(see below) U
No.and Street Type Description
Hampton, NH 03842 U Unrestricted(Buildings up to 35,000 cu.ft.
City/Town,State,ZIP R Restricted 1&2 FamilyDwelling
M Masunry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
603-234-9213 Cminasalli@gmail.com I I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) 117430 10-3-2012
Charles Minasalli HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
10 Hazel Drive. Cminasalli@gmail.com
No.and Street Email address
Hampstead, NH 03841 603-329-6101
Ci /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 .......... IN 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 KTM Properties, LLC
to act on my behalf,in all matters relative to work authorized by this building permit application.
Jill Fame 11/29/12
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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.
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.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
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"