4 BENTLEY ST - BPA-14-1378 ADD WALL TO PREEXIST. STAIRS ov
�( SL, The Commonwealth of Massachusetts REC IVE
1WBoard of Building Regulations and Standards INSPECTIC AL I �S
Massachusetts State Building Code,780 CUR SALEM
Revised Mar 2,011
Building Permit Application To Construct,Repair,Renovate Or DcNi" 0 A % 3 U
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date p ied:
4--w f A/t-
Building Official(Print Name) Signature Da
SECTION 1:SITE INFORMATION
1. a Address 1.2 Assessors Map&Parcel Numbers
l.l a Is this an accepted street?yes ✓ no_ Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rem Yard
Required Provided Requved Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' f Record:
ame(Pnnt) Oi....,e' Qf „:•r? City,State,ZIP
J .fbk -4Y/-C.7YY Atso�w
No.and Street —� Telephone mail Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building l9 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
VDemolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed World: A�� (z)A L A 1 %O �F SSA 12S O/`'
'Lot)
z r AK , /N4
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ d d D, A d 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ , 4/J ❑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 $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 54) , ❑Paid in Full ❑Outstanding Balance Due:
C
SECTION 5: CONSTRUCTION SERVICES
l 5.1 Construction Supervisor License(CSL)
t� `n CS - Jo7G�31 Ial�l lati l>�
2)AvID? L,- 'h.A (L G,AA �� License Number Expiration Date
Name of CSL Holder t� List CSL Ty
pe(see below) y
l a d M � lz 1'
No.and Street Type Description
L�� /V!r i "1� YgJ ,f7� U Unrestricted(Buildings u to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
Gown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
7gJ G96^� l ��"" SF Solid Fuel Burning Appliances
S ,/ryV£ �aA2�.h�/�Ma;�.tL/p1t!j I Insulation
Telephone Email address AAll.•< D Demolition 5.2 Registered Home Improvement Contractor(HIC) a
3 g ,WS
�yi V i �• l�'�C 41A1'n x,1 HIC Registration Number Expirtion Date
HIC Company Name or HI Registrn,Name
Ion
No.and Street Email ad s
1_"J & 7, t�i9�3 `��) 49Irg5a1 -/r,,tL.Co
Ci owwn,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
1,as Owner of the subject property,hereby authorize I& rF
to act on my behalf,in all matters relative ork authorized by this building permit application.
Print Owner's Name(Ele nic Signature) �T 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�tru u /the best of my knowledge and understanding.
✓Ji. t"bGJod ''''ci+/ems (J�if ys� A1/4/4
Print Owner's or A rued Agent's Name(Electronic ignature) Date
NOTES:
1. 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(IBC)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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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"maybe substituted for"Total Project Cost"