0010 1/2 BENTLEY ST - BPA-14-539 VINYL SIDE LEFT x. .20 gid:••--� _ -
G _ le5o
} I The Conmionwealth of Massachusetts
t
� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Slur 2011
One-or Two-Family Dwelling
Building Permit Number: This Section ForOt2icial Use Only "
Date' p 'ed:
r �
BuilJing Official(Print Name): - �
Signator Date
SECTION 1:SITE INFORtNIATION
LI Prupe•ty dress: �---
Z 5-A�5 1.2 Assessors Map Jtr Pa cel_Numbe Q:) }�iQ(j
1.1a Is this an accepted street? es 35" ' S ZS
Map Number Parcel Number
1.3 "Zoning Information:
1.4 Property Dimensions:
Luning District Propose)Proposed Us�—
Lot Area(sq R) Frontage(R)
I.5 Building Setbacks(ft)
Front Yard Side Yards
Provided Re
Require) Provide) Rear Yard
Required wired
y Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information:
Public[3 Private❑ Zone: _ Outside Flood Zone? 1.8 Sewage Disposal System:
Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP!
2.1 Ownyrto Recor � n !(/
iine(Innt) f,Ur ilv,,Vn / �i�r1.Sl CG /'/ =' ,�..FkJ. /"/
City State,ZIP
Telephone Fanml Address
SECTION 3: DESCRIPTI N OF PROPOSED WORK=(check all that apply)
INCw Construction❑ Existing Building Owner-Occu led ❑ Re pairs(s) ❑
Demolition P p O Alteration(s) ❑ Addition ❑
❑ Accessory Bldg. ❑ Number of Units Other
Brief Description of Proposed Work=: 0/Lpeuly, L/ S
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Bwldmg S Z �. I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑St•mdardCity/Town ApplicationFee
3. Plumbing S ❑Total Project Costa(item 6)x multiplier x
2. Other Fees: S
4. Mcchonical (hIVAC) S List:
5. Mechanical (Fire
Su :ressiun) 'S Total All Fees:S
6. Total Project cost: S z — Check No._Check Amount: Cash Amount:_
Cl Paid in Full ❑Outstanding Balance Due:
a i
SECTION 5:
N A /l CONSfRUCTfOSE—w——ES
5.1 Construction Supervisor License(CSL) �R9j--- Es im�tiu Date
License License NumberURGCC
'
List CSL'fype(see below) ,
Name ot'CSL[[olderff���-//��'t' -
0C /'�J.yC._� a Type - Description - l
Unrestricted Bmldin s u l0 35,000 cu. R.
No.and Street C+r/,--y R t
"Lv / Restricted I&Z Pamil nPA C)
Dwellin
�( Mason
City/rown,Slut ZIP ���� RC Roolin CndSin
7�/ �h� WS Window and Sidin
,JJ ] Sp Solid Fuel Burning Appliances
d1�C I Insulation
Ill AVfZ/�✓GCJE'+ D Demolition
------' Emaal address ^
Tcle hone
$2$ Registered ome im '�'e!nent ontrnctor(HIC)
tIIC Registration-ZIELINumber Espiruti)n D;to
N V�/ t G F ) otdC C'
IIIc conn ,ny Nang Il[C RygtstrantN'me
/= � Email ad ess
No.all �treet
'Cele hone .
Ci Crown,Stati! ZIP cz/
SECTION 6:WORKERS'COMPENSAT[ON INSURANCE AFFIDAVIT(M.G.L.c. . Fa l re to
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 ..........13
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
tq act oar my behalf,in all matters relative to work authorized by this building permit application.
Date
Print Owner's Nmne(Electronic Signature)
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 tl ' a plication is true and accurate to the best of my knowledge and understandings )
/Dae
Print Owner ' Authorized Agent arae(ElecUunic Signature)
NOTES:work,or an owner
(An not registered in the Home I reproillog ve entermit tCu do
r his/her
ctor(HIC)Program)will not havetaccess toires an tthe arbitr tiontractor
programnror guaran'tyI tun information It no tiorm ion
loNI s on the Construction tionh5uperver isor Liceant nse can be found at 7—on the atC M�nrms��n`be found at
i. When substantial work is planned,provide '— ...........ludinelgarage, finished basement/attics,decks or porch)
( g
Total tloor area(sq. eJ Habitable room count
Gross living area(sq. Number of bedrooms
Number of fireplaces Number of half/baths
Number orbathrooms Number of decks/porches
rype of heating system Enclosed —Open
j rype of cooling system
}. "rota(Project Square Footage" may be substituted tor Total Project Cost"