B-19-511 - 0003 BERRYWOOD LANE - Building Permit to
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR 2 19 mm ,15 P .�++ M
Revrsedar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-F.amfly Dwelling,
This Section For Official Use Only
t Building Permit Number; Date Applied:
Building OtRc►al(Print Name) Jell. Signature Date
SECTION 1:SITE:INFORMA'!'ION ,
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
3 Berrywood Lane 24 0225.6_
1.1 a is this an accepted street?.yes X 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(R),
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?
Public❑ Private 0 Check if es❑. Municipal❑ On site disposal system ❑
�
SECTION 2• PROPERTY`'OWNEASilw
2.1 Owner'of Record:
Mohamed & Kimberly Shehab Salem, MA 01970
Name(Print) City,State,Z[P
3 Berrywood Lahe 978-223-0376 Mkshehab@comcast.met
No.and Street -"` Telephone Email Address
AAOI ON 3:DESCRIPTION OF,PROPOSED WOR]e(check all that apply) .•
New Construction❑ Existing Building-M Owner-Occupied M Repairs(s) ❑ Alteration(s) M Addition ❑
Demolition 17 Accessory'Bldg.❑ Number of Units Other ® Specify:_Replacement
Brief Description of Proposed W&V: Replacement of 2 patio doors
SECTION 4:ESTIMATED CONSTRUCTION:COSTS
Item Estimate Costs: _ Oflidral'Use Only
(Labor and Materials y
1.Building $ 8 719 1 Building Permit Feet$ Indicate how fee is determined
Application Fee
..
2.Electrical $ LJ Standard,CitylTbiam
O Total Project Costs(Item 6)x multiplier. x
3.Plumbing $ 2 Other Fees,:,$
4.Mechanical (HVAC)
5.Mechanical (Fire r-
S ssion $ Total All Fees"'$
I Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 8,719 ❑Paid'in Full ❑Outstanding Balance Due:
t t.) s p�G:.
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)`
90125 10-06-20
Jamie Morin License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) lJ
30 Forbes Road
No.and Street .1,'pe Description
Northborough, MA 01532 _ U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
-SF Solid Fuel Burning Appliances
508-351-2277 rbabostobpermitting(aandersencorp.com I I Insulation
Telephone Email address D Demolition
5.2 Registered)Home Improvement Contractor(HIC) 170810 12-22-19
Renewal by Andersen HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
30 Forbes Rd rbabostonpermitting@andersencorp.com
No.and Street Email address
Northborough, MA 01532 508-351-2277
C' /Town,State ZIP. .. Tel hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G:L.e.152.§ 25C(6)).
Workers Compensation Insurance affidavit must be completed and submitted with tills application. Failure to;provide i
this affidavit will result in the denial'of the Issuance of the building permit,
Signed Affidavit Attached? `Yes
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 Jamie Morin {'
to act on ray behalf;in all matters relative to work authorized by this building permit application.
See attached contract 5/13/2019 (((
Print Owner's Name(Electronic Signature) Date f 04
SECTION 7b:OWNERr 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 andunderstanding.',
Jaime Morin _ 5/13/2019 1
Print Owner's or Authorized Agent's Name(Electronic 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
(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.
wwwanassaooy/oca Information on the Construction Supervisor License can be found at www.mass.g vo /dns
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 system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"