B-17-573 - 0009 BAY VIEW CIRCLE - Building Permit Ufa The Commonwealth of Massachuset>?s}3
Board of Building Regulations and Standards CITY OF
t4 Massachusetts State Building Code,7800k JUN 22 A It: 3 4 SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official 14e Only
v J Building Permit Number: Date A lied:
l
l Building Official(Print Name) Signature Date
�l
2
SECTION 1: SITE INFORMATION
1.t Pro erty ddress:
1.2 Assessors Map&Parcel Numbers
4 %--1• (,
1.la Is thi an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) 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,§Si) 1.7'Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 0 Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'of Recor
rt��Ltvoz-c. LEm MA
Name(Print) City,State,ZIP
Noland Streh Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Constriction❑ Existing Building Owner-Occupied W1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brie DesT 'on of Proposed Work2: �` a f
T i it a
).
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: .
bor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
0 Total Project Cost'(Item 6)x multiplier x
3.Plumbing $
2. Other Fees: $
4.Mechanical (HVAC) $ -List:
5.Mechanical (Fire
Suppression) $ Total All Fees:'$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3�1 0 paid in Full' 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) O r'p,r •(8
—i " 1 '�K MIs 0 1A 1 License Number Expiration Date
Name of CSL older �
Q ¢ i� List CSL Type(see below) L/
No.'
aUn Street 'J Type Description
U Unrestricted Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
CityAown,State,ZIP M Mason
ry
RC Roofing Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
So 8"ZOO• D I jL I Insulation
Telephone Email address D Demolition
5.2 Aegistered Ho a Improvement Contractor(HIC) fA
f
HIC Registration Number Expiration Date
HCrC�mp Name or HIC gistrant Name
No d Street Email address
I"frpt D l� G 1D ply SOD A
City/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 m
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest rider p 'ns and penalties of perjury that all of the information
contained in thus application is true an ace to to a st of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(EI tr is Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who lures an unregistered contractor
(not registered in the Home Improvement Contractor(I-lIC)Program),will not have access to the arbitration
program or guaranty find under M.G.L.c. 142A.Other important information on the IBC Program can be found at
};E cr.mass.*o;°l<mca Information on the Construction Supervisor_License can be found at www.mas, .goival
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 syst
em Enclosed —open
3. "rota]Project Square Footage may be substituted for"Total Project Cost"