17 BENGAL LN - BPA-2009-694 REPLACE 2 SLIDING DOORS y The Coninioimealth of 19assachusetts
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13uarJ of Budding Rcguhuiuns :utd Stand:uds \II'NIl'IP U.I'il
L.' NJ ssachusetts State l31lilding Code. 7S(I CNIR. 7"'edition
Building Permit ,-application To Construct. Repair. Kenocate Or Ucmulish a PrI.houn,
i
Ont'- or Tn'n-F Dtrrllrn,q _oos
This ' cti )n For 0 filial Use Only
Building Permit Nam r: e Applied:
q110 -- --. - ----
Si,snature: .
131ildine Commissioner/ super or of Buddiu- Dale --
S L SITE INFORMATION
Ll ro rty ldclre C1 11.2 Assessors Map & Parcel Numbers
ala Numher Parcel Nmnhcr
I.I a Is this an accepted street? yes_ no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy li) Frontage ili)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Recoiled Provided Required Provided Required Prueidcd
1.6 Water Supply. (M,G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone" - Municipal-0 On site disposal system ❑
Public❑ Private ❑ Check ityes❑
SECTION 2: PROPERTY OWNERSHIP'
MA �
eco /6„ / /
.Address 1'or S-h ice:
Telephone
SECTION 3: ESCRIPTION OF PROPOSED WORK'(check all that apply)
❑ Existing Building ❑ Owner-Occupied ❑ Repairs(sl ❑ Alteration(s :Wdition ❑
❑ Accessory Bldg. ❑ Numbenrt'Uni[s_ Other ❑ Speedy:
Brief Description of Pry use Wo k--
'SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item - (Labor and Materials)
I. Buildine $ '� Op I. Building Permit Fee: $ Indicate how tee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost} (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
). Mechanical iHVAC) $ List:
!
5. Mechanical (Fire $ --
Suppression)
Total All Fees:
i
Check No.. Check Amount: ('.uh :\nnwnc
j 6. Total Project Cotit: $ �fo3_� 0 Paid in Full 0 Outstanding Balanic Uue:________—
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) -7-�3 _ ��� _ l7�/*��•
License .Numhet F.�pir:won Ualc
,Fame of('SL- Ifofolyldd�err .y,_ l
SI / P P"i - Lul CSI.I\pc(.,co hcluwl
WJres �— 1\' c Ihsrn�uun
C t'nn•sviaed ui l nt 34 .11110 Cu. H.i
R R0111CIed I&@'_ Fanuh Dwcllim,
s1e°IlfO Only
Reside
RC Residential Hootin¢l'ocnne
Trlephone \\'S Renulcnoal R`indu .uiJ .i iJme
SF Residential unmie "'armCc lu.ialLwt�
D Re,iJaival Demolition
5ARegi'lered ilome Improvement Contractor(111('1 l D)�Od-t
y' SeTVIrpS =nom --
filC Company Vann or HIC R-isumri Name Registration `umber .
ilkp+� lin 6Da��o �a20 C)
%Jdress (9�18)7H1-bJ4Aq ' p
Fx I ahun Det(
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. I52.§ ?5C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure ai prueide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No..... ..... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN .
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, . / 1 - , as Owner of the subject property hereby
C
authorize hri t'D17b'1Pl" rZig` to act on my behalf, in all matters
relat7�ta work:mthorize 9-Dy his b ding permit application.
X _
'Signature ul Ow.ner 1 Da
SECTION 7 ; OWNER' OR AUTHORIZED AGENT DECLARATION
[, r h I S•17),QkV Y ZO U-0 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foreguing application are true and accurate, to the best of my knowledge and
behalf.
r
Print N e
�� 3ct-OGi
Sigrin ure o hwntr orhorized Agent Date
(Siened under the gins, d penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an Unregistered Cpntraaur
(nut registered in the Home Improvement Contractor(HIC) Program). will not have access to.the ;ubinatiun
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSU can be found in 750 CMR Regulations I IO.R6 and I IO.RS, respectively.
When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) iincluding garage, finished basemenUattics, decks or pm-chi
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedroom,
Number of hwhrooms Number of halt/hath,
fvpe of heating system Number of deck,/ perches ---___---
hype of cooling system . Enclosed Open _--- -- --
3. "Total Project Square Footage' may he substituted @n' "Total Project Com-