B-19-279 - 0022 BENGAL LANE - Building Permit iP I
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the Commonwealth of Massachusetts
` Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revlsed Mar 2011
(� Building Permit Application To Construct,Repair,Renovate Or Demolish a
1 One-or Two-Fmnily Dwelling, i
_Thrs Section Fof' f
,Offtcial�UseOri1`
�Buildmg-P mtt Nvnnber:� - � +Date Appl�l.
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^wlldiug Of&ciai;(Pint Name} .. Sigee Date
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' - SECTION l:SITE INFORMATIO . s
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers '
22 Bengal Lane 12 12-0001-824 _
1.1 a Is this an accepted street?yes x no Map.
Number Parcel Number F
13 Zoning Information: 1.4 Property Dimensions:
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Zoning District Proposed Use Lot Area.(sq fl) Frontage(tt)
1.5 Building Setbacks(fl)
Front Yard Side Yards Rear Yard
Required Provided Required 'Provided Required Provided
1.6 Water Supply:(M.G L c.40,§54) L7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 17 Private O Zone: Outside Flood Zone? M
Check if esEl unicipal 0On site disposal system 0
SECTION2 )PROPEI&Y''OWNERSHIF'1 _
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2.1 Owner'of Record:
Chris Adkerson Salem, MA 01970 i
Name(Print) City,State,21P
22 Bengal Lane 978 836 8594 cadkerson@verizon.net
No.and Street -- Telephone Email Address
T[�N 3•DESiCRIPTION,OF.PROPOSED WORK' ctiecit all ffiat appiG
New Construction O Existing Building M Owner-Occupied ® I Repairs(s) 13 1 Alteration(q) ® Addition O
Demolition 11 Accessory Bldg.O Number of Units Other ® Specify:_Replacement
Brief Description of Proposed Works: Replacement of 1 patio door
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_ SECTION4:ESTIMATED CONSTRUC"1TON!;COSTSr'w
Estimated Costs:.
Item and Materials , UffldalUse.Oaly-..,
1.Building $ 3474 x 1r;BuildingPermitF®e:$' `Indicatehow'fee is determined'-,,
Electrical $ ;OStanda�lCily/To nApplicationFee _~
.2. I3 Total Project Costa;(Item�x multiplier _ .x
i3: 3:Plumbing $ 12�Offer Fees: $
4.Mechanical OWAC)
5.Mechanical (Fire - '
" S ion $ Total All Fees;$ ;
Check No. .Check Amour Cash Amount`
6:Total Project Cost: $ 3474 '13 Pa Jk Full Outstffitd ng'Balar►ceDae t I
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SECTION S:.CONSTRUCTION SERVICIE3 `e
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5.1 Construction Supervisor License(CSL) 90125
10-06-20
Jamie Morin License Number Expiration Date
Name of CSL Holder
30 Forbes Road List CSL Type(see below) _�—
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No.and Stet .IYPe� ? � - Desca�pttoa1•
i U Unrestricted'(Buildings to 35 000 cu.ft.). ,
Northborough, MA 01532 R Restricted 1&2 Family
Dwe
City/Town,State,ZIP M Maw
RC Roofing Covering
# WS Window and Siding
j SF 1. Solid Fuel Burning Appliances o
508-351-2277 rbabostob ermittin andersencor .con I ���p Q� p
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 170810 12-22-19
Renewal by Andersen HIC Re
HIC Company Name or HIC Registrant Name Registration Number Expiration Date
30 Forbes Rd rbabostonpermifting@andersencorp.co p g@andersencorp.com
No.and Street Email address
Northborough, MA 01532 508-351-2277
City/Town,State,ZIP Telephone
'SECTI0NI,6 WORKERS'COIIViPENSATION INSURANCE AFFIDAVIT(IyI.G.L.�c.152..to 2SC(6)) .
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will rmh in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........® No...........❑
j 8ECTION;7ae OWNERAUTHORtZ`ATION:TOBE'COMPLETED WHEN
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OWNER'S`AGENT_OR CONTRACTQR=APPLIES kOR BDIL-DING PFRNIIT Y _
I,as Owner of the subject property,hereby authorize Jamie Morin t
i to act on my behalf,in all matters relative to work authorized by this building permit application.
See attached contract 3/18/29
! Print Owner's Name(Electronic Signature) Date "
SECTION'7la UWNER''OR AUTHORIZED.AGENT DFc�r ela eTION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information Y
contained in this application is d accurate to the best of my knowledge and understanding.
Jaime Morin 3/18/29
` Print Owner's or Authorized Agent (Ele nic 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. t
(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 oovl-=Information on the Cansrcction Supervisor License can be found at www.mass.g vo /dos
2. When substantial.work is planned,provide the information below:
Total floor area(sq.fQ (including garage,finished basement/attics,decks or porch)
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Gross living area(sq.ft.) Habitable room count
' Number of fireplaces Number of bedrooms -
Number of bathrooms Number of half/baths
Type of Beating system Number of decks/porches
y Type of cooling system Enclosed Open
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3. "Total Project Square Footage"maybe substituted for"Total Project Cost„