REPLACEMENT DOOR IN 2A $ Zr-c,« q b0 q l
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
'this Section For Official Use,
Bwdm�Pierm�trNuin'be�� �� - _ >Date ,.:.]red:,:. __-.•,t-�.:
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SECTION I:Sm II"RMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
2 Fletcher Way,Apt A 22-0001-901
1.1 a 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) Frontage(ft)
1.5 Building Setbacks(B)
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 Infermtion: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public O Private O Check R Municipal E3 On site disposal system
' 'SECT[01�T tPF� 11R8HIPtk . '
2.1 Owner'of Record: i
Ann Cocci Salem, MA 01970 --i
Name(Prim) City,State,2211?
2 Fletcher Way,Apt 2 978-766-1754 amcocci@comcast.net '
No.and Street Telephone Email Address cn :r
;I ON 3:DESCRI)P'1~ION OF PROFUSED WORKS( itil thit apply) r=
New CmrsWaWon 17 Existing Building 0 Owner-Oecupicd 0 Repairs(s) 0 Alteration(s) ® Addi' O
Demolition O Accessory Bldg.O Number of Units Odkw M Specify:_Replacement ry
Brief Description of Proposed Wont?`: Replacement of 1 door
SECTION 4eFAtip,$TIMASfED, li$TRUtIt�lYS:
sted Costs:
Item ° 015 4l'UtM 0*
(Labor and Materials)
1.Building $ 5584.00 1 > gl�eamrtFee: ileess
own .. ,
2.Electrical S 3tandacdityI` Ap�hco�on Fele
O Total Project Costs(llrm ox er x
3.Plumbing $ 2. Other Few. $
4.Mechanical (HVAC) S Lust:
5.Mechanical (Fire $
S on) Total All Fees.$
Check No._Chedk Amami: Cash Amount:
6.Total Project Coat: S 5584.00 0 Paid in Full 0 Outstanding Balance Due:
�1ra Lci�o 1 r-) Sp)SE� ��� �
SECTIONS: CONSTRUCTION 3ERYICES
5.1 Conduction Supervisor License(CSL) 90125
10-06-18
Jamie Morin License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
30 Forbes Road
No.and Shset ,
Northborough, MA 01532 U Unrestricted to 35,000 cu.R
R Restricted 1612 Family Dwelling
Cityfrown,State,ZIP M UMMY
RC Roofing Covering
WS window and Siding
SF Solid Fuel 13uming Appliances
508-351-2241 rbabostobpermitting(aD-andersenc2M.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvessent Contractor(1lIIC) 170810 12-23-17
Renewal by Andersen
1-UC Company Nance or HIC Registrant Name HIC Registration Number Expiration Dente
30 Forbes Rd rbabostonpermitting@andersencorp.com
No.
MA 01532 508-351-2241 Email address
City/Town,State,ZIP Telephone
SECTION Q*9RK 5'COMPENSATION CR AFFIDAVIT(M.G.L.'e.11
Workers Compensaton Insurance affidavit must be completed and submitted with this application. Failum to provide
this affidavit will result in the denial of the Issuance of the building pamit.
Signed Affidavit Attached? Yes..........M No...........0
SitC ON aA 'H(i ``TTON T6 Nzt3( MPS
,.
� ���RAI'�PL'i �1li �
I,as Owner of the subject property,hereby authorize Jamie Morin
to act on my behalt;in all matters relative to work authorized by this building permit application.
See attached contract 4/3/17
Print owner's Name(Electronic Signature) Date
SECTION 7b:w0'WNERr OR AUTHOIt1D AGRNT OF.ivLAt �I'tON
By entering my name below,I hereby sins and penalties of perjury that all of the information
cmWined in this application is accura of my knowledge and understanding.
Jaime Morin 4/3/17
Print Owner's or Agent' echonic Signature) Date
s
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 was have access to the arbitration
program or guaranty fiord under M.G.L.c. 142A.Other important information on the HIC Program can be found at
IMMM ssogf oca Information on the Construction&Wvisor License can be found at www.mass.Qov/dns
2. when substantial wank is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross)ming area(sq.fQ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of haWbaths
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"