23 PATRIOT LANE BPA-17-204 12-(,o cl; 13 3y
The Commonwealth of Massachusetts
Q Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR 2011 MAR 23 P 4044
Revised Mar 2011
- Building Permit Application To Construct,Repair,Renovate Or Demolish a
n One-or Two-Family Dwelling
C� This Section For Official Use Only
Building Permit Number: Date lied:
%4w.4 r
Building Official(Print Name) Signature Date
(� SECTION 1:SITE INFORMATION
�+ 11 atrlot`Lane, Salem, MA 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sqft) Frontage(ft)
1.5 Building Setbacks(ft)
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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2P,oVfr "erta Soltz Salem, MA 01970
Name(Print) City,State,ZIP
23 atrot Lane (978) 741-2770 bob@ownproperty.co
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed WorV: Replace 5 windows. 4 Sliding glass doors and
1 entry door
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:S Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 189215.00 ❑Paid in Full ❑Outstanding Balance Due:
� )l 2�-s L-MOIN-1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 096660 05/08/2018
Michael Potasky
License Number Expiration Date
Name of CSL Holder U
592 Salisbury Street List CSL Type(see below)
No.and Street
Worcester, MA 01609 Unrestricted(Buildings up to 35,000 cu.ft.
Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
508 847-1891 SF Solid Fuel Burning Appliances
potasky15(a�chartenne I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town,State,ZIP Telephone
SECTION 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 authorize Michael Potasky
to act on my behalf,in all JWM relati a to work a rized by this building permit application.
Robert Soltz 3/23/17
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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 this application is true and accurate to the best of my knowledge and understanding.
ichael Potasky 3/23/17
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
,www.mass.gov/oca Information on the Construction Supervisor License can be found at wxNiv.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor 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"