BPA-17-262 ` The Commonwealth of Massachusetts
�- Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
r Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
WT
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1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
10 Patton Road 22-0195-0
11 a h this an accepted street?yes X no Map Number Parcel Number
1.3 Zoafarg Information: 1.4 Property Dimeasions:
R1 one faro
Zoning District Proposed Use Lot Asea(sq R) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Raluired Provided Requited Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Inferoation: 1.8 Sewage Disposal System:
Public O Private D fie: — tv Outside
eck if
Zone? Municipal 0 On site disposal system 0
2.1 Owner'of Record:
Vilma Pacheco Salem, MA 01970
Name(Print) City,Ste,ZIP
10 Patton Road 978-766-1754 vilma.maria.pacheco@gmail.com
No.and Street Telephone Emat7 Address
& �t1N FSICIt lg�1*TOF V�ORK Y all tit a
New Canstrucdon o Existing Building® Owner-Occupied ® Repairs(s) l7 Alteration(s) ® Addition D
Demolition 0 Acoessory Bldg.O Number of Units Other ® Specify: Replacement
Brief Desmiption of Proposed Worl?: Replacement of 1 patio door
Item
Estimated Costs: 177
aAbor and Mamerials 4 !1s8 '
1.Building $ 6788.00
2.Electrical S p Total Project Costs° t)x mtalia _ x
3.Plumbing $ 2- to laces: S
4.Mechanical (HVAC) S USL.
5.Mechanical (Fire $ Total All Fees:S
S 'on
Chock No. Check Amotmt: Cash Amount:
6.Total Projekt Cast: $ 6788.00 0 Paid in Full 0 Oatstauft Balance Due:
R
5.1 Constraetbn Supervisor License(CSL) 90125 10-06-18
Jamie Morin LieenseNumber Expiration Date
Name of CSL Holder List CSL Type(see below) U
30 Forbes Road
No.and Sheet .
U Unrestricted to 35,000 cu.R
Northborough, MA 01532 R Restricted 1&2 Family Dwaffing
City/Town,State,ZIP M
RC Roofing Cavaing
A- D
Window and Siding
ees
Solid Fuel Burning AppHsn
508-351-2241 rbabostobpermitting(cD_andersencorp �
Telephone Email address Demolition5.2 Registered Home Improvement Contractor(RIC) 170810 12-23-17
Renewal by Andersen HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
30 Forbes Rd rbabostonpermitting@andersencorp.com
No.and Street Email address
Northborough, MA 01532 508-351-2241
City/Town, ZIP T`'
SECIZON�ts�wORiiBRB'COMPENSATION�iI•�AFFIDAVIT t�.C:�� sx.�#4' )fi„U ,
Workers Compensation Insuraie affidavit must be completed and submitted with tins application- Folu a to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........M No...........D
1,as Owner of the subject pmaperty,hereby authorin Jamie Morin
to act on my behalf;in all matters relative to work authorized by this building permit applicatlion.
See attached contract 4/10/17
Print Owner's Name(Electronic SignAtm) Date
B3'entering my name below,I borethe pains and penalties of perjury that all of the information
contained in this application' and the best of my knowledge and tnderstmnding.
Jaime Morin 4/10/17
Print owner's utborized Agent' 91CWcaomc Signature} Date
rO
1.,. An Owner who obtains a building permit to do his/her own wait,or an owner who hires an urmmgistered contractor
(not registered m the Home Improvement Contractor(HIC)program),will war have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Ot w important information on the HIC Program can be found at
www.mass.nU LqB Information on the Carrst action Supervisor License can be found at wwwmWW.8ov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.fl.) (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/batbs
Type of heating system Number of decks/parches
Type of cooling system Enclosed open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"