205 ESSEX STREET - BPA-12-149 i
The Commonwealth of Massachusetts
° Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7a'edition
Building Permit Application To Const t,Repair,Renovate Or Demolish a Revised
One- or Two-Fam'ly Dwelling Aril 15, 2009
This Section FoA Official e Only
Building Permit N ber: Ap ieedd: Q
Signature: Z) D
Building Commissioner/Inspector of BuildingsTif VDate
SECTION l c JVfE INFORMATION
1.1 Property dress: 1.2 Assessors Map&Parcel Numbers
A6 sk
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 ft) Frontage(It)
1.5 Building Setbacks(it)
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 liySu Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal n site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Awnert,of Re ord:
VA
Name(Print) AVrees to Se
� rvice:/ r
q �— ( J' Z �
i9 Signature Telepfione
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SECTION 3:DESCRIPTION OF PROPOSED WORK' (check all th apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief,gescnption of Proposed ork2: �`
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ ' 1. Building Petmit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ 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
76Total
ession Total All Fees: $
Check No. Check Amount: Cash Amount:
Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
r .
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) f
(Q.kt�� License Number Expirauon Date
me of C-SL- older 3
List CSL Type(see below)
dre s e Description
U Unrestricted(up to 35,000 Cu.Ft.
Restricted 1&2 Family Dwelling
M Masonry Only
/(L � RC Residential Roofing Covering
Telepho e WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2Y
istered ome Itubro t Co rac or(HIC)
M om any e or I Reg tt Name Regt rst ation Number
Ad s q
;M1`L
o � Expiration Date
Sign re eIepho e'
ECTION 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
(�WP authorize to act on my behalf, in all matters
relative to work authorized by tbis bui i ermit application.
Signature of Owner Date
,//��
ECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
4aI, c as Owner or Authorized Agent hereby declare
that the statements and information foregoing application are true and accurate,to the best of my knowledge and
behalf. ny�
Frig(�S2mv/ liU��/✓! � g 2 d J�
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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(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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
University 6f Cincinnati
Occupational Health & Safety Continuing Education Program
Co-Sponsored by Environmental Training Institute, LLC
ED WAS KEENAN
Keenan C'ppnstruction
32 PoI Street
Beverly,MA 01915
I
Has Successfully Completed the 1
Lead Safety for Renovation, Repair and Painting Initial Course
C".. _
F61"NJ
Program Di!!0610 Course Principal Instructor
R-I-18459-10-00678 8
Certificate Number Continuing Education Units
April 19, 2010 April 1, 2010
Issue Date Language— English j. Course Date
I
I
Occupational Health &Safety Continuing Education, UC Reading Campus, 2180 E. Galbraith Rd., ML 0510,Cincinnati,OH 45237-1625, (513)558-1730,
www,eh.uc.edu/hsce
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