B-17-729 - 0112 BAYVIEW AVENUE - Building Permit CA<- 3 l a-o
a commonwealth of Massachusetts
OF
} `Bd of Uding Regulations and Standards CITY M
Massachusetts State Building Code,780 CMR Ste'
tt��� Revised Mar 2011
) l P�ertit A$plk'atrarl To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
1 finis Sin lire
- ,.
13d;ag Prnilt Iir`. : Date li®d
1 �gC1��l(Pril3tie)
SECTION l..i�ITlI:' il�1A7IO�1 :.
1.1 Pro ddress: 1.2 Assessors Ma &Parcel Numbers
Pe P
1
'A Map Number Parcel Number
1.1 a�I this an acce d street. es no
s y
13 Zoning Information: 1.4 Property Dimensions:
ZQnuig 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal 0 On site al stem ❑
Public @ Private❑ — Check if yes❑ P disposal system
SECTI�N2 PRflI"1�.TYOERS 'i` .,
2.1 weer'of Record:
Name t � CVatc,
7 '
�—
No.and Street (�
Telephone cAmaii Address
SECTION 3:DESCItII;T1€ON OF PROPOSED WOJW (oheck all that.app1Y)
New Construction❑ Existing Building Or Owner-Occupied ❑ 1 Repairs(s);® I Alteration(s),Pk Addition ❑
Demolition t, Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description o Pro se Work Z:
SECTION 4:ESTIMA;T D CONSTRUCTION COTS .
Item Estimated Costs: Official Use Only
(Labor and Materials . :.
1.Building $ 1., Build(rig Permit Fee.$ . Indicate how fee is determined:
13 Standar4 City/rowu Application Fee
2.Electrical $
O Total Protect Cosh(Item b)x multiplier x
3.Plumbing $ 2: Other Fees
4.Ivlechanical (HVAC). $
List:
5.Mechanical (Fire $ Total All Fees:$.
S ression
®D C heA No. Check Amount: Casli Amotint:
6.Total Project Cost: P-4 01 13 1'siei in mil 13 OutsEag ' Ba3actcri
�I0�15 C(1��TIR�3CT�Ohi tTrIC ' �
5.1 Construction Supervisor License(CSL)
• License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street � _ T h�
U Unrestricted 0M!!jpE up to 35,000 cu.ft.
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
' . RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
r I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Tel hone
s> WG fiER A COMPENSATION 1 URMCE A]WMAVIT(XG L,G 14
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...........❑
ECT1 i 7a: R AU7`TI JRII(;A Olv`Tb B to L Ep was
(}l'ff1 E i'S TIT Oit CUNT_U f.)R
1,as Owner of the subject property,'hereby authorize !. i
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 lb-6*i4W OR*UTH0RIZED AGENT I}�TIUI
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 fife and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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
%i wnv.mass.gsov/oca Information on the Construction Supervisor License can be found at www mass.gov/das
2. When substantial work is planned,provide the information below: ,
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
SECTION 5c 'CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) p6,L� , q 7 Ib l� /^'f
License Number Exp' anon Jate
Na a of Holder
� � List CSL Type(see below)
No. nd Street tO
Type Description
Unrestricted(Buildings up to 35,000 cu.ft.)
Restricted 1&2 Family Dwellin
City/ ,State,ZIP M Masonry
RC Roofing Covering
f� � WS Window and Siding
SF Solid Fuel Burning Appliances
Clam, (L(aAh I Insulation
Tele'hone Email ess D Demolition
5.2 R,egist red H me Impro rn t Contractor(HIC) f
L- H�CKgistration Number pira on Rate
HIC ny f a or H C Regis ant Name
r U
No a S eetft
City4own,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L c.152.
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 .......... I No...........❑
SECTION 7a:OWNER AUTHORIZATION-TO BE°COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORI APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize LeJoMi
to act on my behalf,in all matters relative to ork authorized by this building permit applicati
4 C,Lv� -�� Q
Print Owndd Mame(Electrons a Date
SECTION 7b:OWNER'."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.
F14
Print Owner's or Authorized Agent's Name nic Si e) D to
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.mq L og v/oca Information on the Construction Supervisor License can be found at www.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 hanaths
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"