43 BAY VIEW AVE - BPA-12-511 REMOVE CHIMNEY t
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7, The Commonwealth oFMassuchusetts
i� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNIR SALEM
Building Permit Application To Construct, Repair, Renovate Or D, '-h a He rived.16u'2011
One-or Ttvo-F mill Un elling
This Section For Official Use Onl
Building Permit Number: __ to Applied:
ll d81�1 IAuIJmg Olisial(Print N,une) Signalur Dale
SECTION I:SITE INFORMATION
LJc P per Ad�dre (gam ` �� 1.2 Assessors Nlap& Parcel Numbers
1.la is this an accepted street?Dyes no Map Ntuoh r Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zon ing District Proposed Use Lot Area(1111) Frontage(f)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone' _ Outside Flood Zone?
Check it' es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2 1 Owner'of Record:
P„ t l s wt R/I ,Qc
Nurne(Print) (.ity.Slate.l.IP
o ai +3a 7- � llwtstsr� e cc>�rtca
No.and Slrtta — relep—hone — timail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ ::i I iltg Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Numberof Units Other ❑ Spccit'y:
Brief Description of Proposed Work-: U — 3
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ I. Building Permit Fee:5 Indicate how fee is determined:
]. E'Iccirical g ❑Standard City?otvn Application Fee
?. Plumbing S ❑Total Project Cost'(Item 6)x multiplier
_. Other Fees: S
4—Mechanical (I11':1('1 S '5bD Za`p List:_ __
-i \lechanieal (fire --- -.
Suppression 'total :\Il Fees: S
o. Total Project Cost: S Check No, ----('lie,k:\mount: _ _-- (',ash ;\mount:
❑ Paid in Full ❑Outstanding BahmCe Due:
S-�0 0
)
SECTION 5: ('ONSTRUCTION SERVICES
5.1 ('onstruction Supervisor License(C'SL)
License Number G\pirnian Date
N;unc ol'l'SI. I InlJer
List CSI.1)pe Use below)
-. ------------- 'I\pe Description
No. and Street ----'—
U 1 iorestriocd(Buildings oli to 35,000 cu. It.l /
R Restrietcd L@'_ Ftmil l Duelling
Cirri fort n,.Stntc,LlP M M1lason
RC Roolin Coccrin
_ W'S Window and Siding
at � �DSO SF Solid Fuel Bruning Appliances
Insulation
'I'cle bona Ismail address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Expiration Date
I IIC C'ontpan) Name or I IIC Registrant Name
No.and Street Email address
City/Town.State,ZIP 'felt hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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
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: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.
,.o.�s �, t'�ll J .. I I l2
Print owner's or:M1uthori zed Agent's Nun .cctronic Signature) Dale
NOTES:
I. :1n Owner who obtains a building permit to do his.her own work,or in owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will rpr have access to the arbitration
program or guaranty fund under.M.G.L.c. 112A.Other important information on the HIC Program can be found at
wwo m.v,. •,yt. �v.i Information on the Construction Supervisor License can be found at
2. When substantial work is planned, provide the information below:
Total floor area(sq. R.) (including garagt, linished basnmutCattics,decks or porch I
Gross living area I sq. 11.) _ Habitable room count
Number of fireplaces_-, Number of bedrooms
N'umherofhathrooms _ Number o(halfhaths
1)pe of heating Sy stem Number of decks, porches
I\Ile of coolllt_L' sy stein _ _ _ - Pnclosed _ _- _Open _
1. -l ot;d Project Square Footage-may he suhaituled for"Total Projat Cost-