7 REPLACEMENT WINDOWS l The Commonwealth of Massachusetts j"16 CEC 29 f 1 Cf*OF
_ Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR Revised M=2011
Building Permit Application To Constzuct,Repair,Renovate Or Demolish a
One-or Two-Fonfly we lin
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N 1.SITE
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
65 Valiant Way 21-0041-865
Lla Is this an accepted street?yes X no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Fmntege(R)
1.5 Building Setbaeb($)
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 lubrosation: 1.8 Sewage Disposal System:
Public O Private 0 Zone: Outside— Chock flood Zone? M 0 On site
unicipal disposal system O
yoD
2.1 Owner'of Record:
Anthony Pikus Salem, MA 01970
Now(Print) City,State,ZIP
65 Valiant Way 508-527-1207 _tpikuscom@gmail.com
No.and Sftd Telephone Emarl Addmas
New Construction O Existing Building 0 ows--Oxupiod ® Re xd*s) o Alteration(s) IS Addition o
Demolition E3 Amessary Bldg.O Number of Units Other M Specify:_Replacement
Brief Description ofProposed Work=: Replacement of 7 windows
.. e. ,.,» :+r.^ ..• , �.,.p.r,rw x, wr+lr vs. �x:.m✓^�3 'ka-4�,°w`
SEGNe " '�
Estimated Costs: '� ` ` '" ,•` "�`
Item aAbor and Materials) •—.
, `
.1.
i.Buil $ 11350.00d �"» :. �
2.Electrical S 17�L ty fl_ni
D Total Projesct Costs Otibi 6)tt a
3.Plumbing S I OlbiirFees: S
4.Mechanical (HVAC) $ LisL
5.Mechanical 0% S
Suppression) Total All Fabs:S
Check No. C 1ac]c Amouat Cash Amounts
6.Total Project Cost: $ 11350.00 O Paiid'h Full 0 Outstanding Balance Due:
Mrs,Lz2:xD sAs>✓ l y t ►�
5.1 Constracdon Supervisor License(CSL) 90125
10-06-18
Jamie Morin License Number Expiragon Date
Name of CSL Holder
30 Forbes Road List CSL Type(see below) U
No.and Street .:
Northborough, MA 01532 U Unrestricted bo 35,000 cu R
R Restricted 1dt2 Family Dwelling
City/Pown,Stabs,ZIP M Masonry
RC Rooftx Covering
WS Window and Sidling
SF Solid Fuel Burning Appliances
508-351-2244 rbabostobpermitting(cDandersencoM.com I Insulation
Te hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 170810 12-23-17
Renewal by Andersen HIC Registration Number Expiration Date
AIC Company Name or HIC Registrant Name
30 Forbes Rd rbabostonpermifting@andersencorp.co
No.and Street Email address
Northborough, MA 01532 508-351-2244
City/Town- ZIP T
111=614&I WORKERS' AFFIDAVIT CQMPENSATION lQVSi[JRANCE G.L.
. .., k ._ . ..
Workers Compensation Insurance affidavit must be completed and submitted with this applic atim Faffim to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........181 No...........E3
R R.�
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SIM __
I,as Owner of the subject property,hereby authorize Jamie Morin
to act on my behalf,in all matters relative to work authorized by this building permit application.
See attached contract 12/15/16
Print Owner's Name(Electronic Signature) Date
v., _ 3EC'TION`7b.O';�i!ItTER'Olid► � AGli<1�1T.�,�' :iAl` .
By entering my name below,I hereby aitest uutdez ains and penalties of perjury that all of the information
contained in this application is true and garrote the best of my knowledge and understanding.
Jaime Morin w 12/15/16
Print Owner's or A s!!!s'9(Elec#oCc Signatune) Date
iY: ,V!. s._ '°'s: ` 4 'Tidy- -11
1. An Owner who obtains a building permit to do his/her own work,or an owner who lives an um vg mWred contractor%
(not registered in the Home Improvement Contractor(FIIC)Program,),will not have access to the arbitration
program or guaranty fimd under M.G.L.c. 142A.Other important information on the WC Program can be found at
www.mM.Vyfoea Information on the Construction Supervisor License can be found at www.mass.gn*g
2. When substantial work is planned,provide the information below:
Total floor area(sq.8.) (including garage,finished basementlattics,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 substiturted for"Total Project Cost"