81 BAY VIEW AVE - BPA-2009-790 CLOSE IN PORCH (BATH, LAUND.) I Oq
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The Commonwealth of Massachusetts
r t�} Board of Building Regulations and Standards Town of
i Massachusetts State Building Code. 780 CMR, Ts edition Building DeptDept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Onu-or Pani(Duelling Amiga
This Section or Official Use Only
Building Permit umber' I Date Applied: �? '
I
Signature: �l ' (5' ey at
Building Co mission cr/ s r of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address:• 1.2 Assessors Map& Parcel Numbers
I.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 La Area(sq ft) Frontage ift)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water upply:(M.O.L c.40,554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
Q tt__SECTION 2: PROPERTY OWNERSHIP' ,tom
2.1Mrertg0ecor�d): E. Y1ovJ _ �� A �Z� .����/
Nam (Print)�1 C*— Ad ess for Service:
Sign r Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building 18, Ownor-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
r ..
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 60 p 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
O b ❑Total Project Cost'(Item 6)x multiplier x }
3. Plumbing S 3 O 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression "' Total All Foes: S
Check No. _Check A aunt: Cash Amount:
6. Total Project Cost: S S U aid in Full ❑Outstanding Balance Due:
emz4K 04-6� Fork
2
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/moi9, `r.
5 � + 04
SECTION 5: CONSTRUCTION SERVICES t
5.1 Licensed Construction Supervisor(CSL)
.. CS OCCI O License Number Expiration Date
N.4mc of CSL- Hpldcr List CSL Type(sec below) - J
it SK,
AJJre RD
RResidential
Descn uon
ted u to 35,000 Cu. Fl.)
Signatur d I&2 FamJ Dwellin
Z p Onl
O ag ial Roofin Coverin
Telephone ial Window and Siding
ial Solid Fuel Burnin A fiance Installation
ial Demolition
5.2 Regis�t:d Home Improvement Contractor(HIC) a�� (.
�.�� Z6ct 1� — 1HIC Cho Ppany Name or HIC RegistrantLame Registration Number
` F L2 URy n l
Address {�
5:2.g 0�Z Ii'L) Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152.4 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 .......... O No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
[authonz
NER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
� `� 1`1 d Cf t C� to act on my behalf, in all matters
iv t work authorized by this building permit application.
ture of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1. `` C7 C-<—k C> ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
6
Print N
Signa of O ner 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 110.116 and I I O.RS, respectively.
2. When substantial work is planned,provide the information below: i
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 hal(/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"
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