51 BAY VIEW AVE - BPA-15-1090, REPLACE WINDOW (:A5ti
S The Commonwealth of Massachusetts ECE v
Board of Building Regulations and Standards INSPEC110F1 ' VICES
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or DemolMy U T —1 A 10r 0
One-or Two-Family Dwelling
This Section For Official e Only
Building Permit Number: Date A lied:
Building Official(Prim Name) - Signature - Date,
/1 SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers
I � 6Lkx lli Eid A"t
U , 1.1 a1.I a I�epted 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Check if yes❑Outside Flood Zone? Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
SI 7�- -71/5--_D
NoNo.an� Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work: E —
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
La or and Materials
1.Building 1. Building Permit Fee:$' Indicatedetermined;
2.Electrical $ _ ❑Standard City/Town Apphcatio e -
❑Toher Fees:
Cost'(Item multipfier x
3.Plumbing $ — 2. Other Fees: $ -
4.Mechanical (HVAC) $ _ List:
5.Mechanical (Fire $ _ _
Su ression Total All Fees:$
Check No. Cheek Amount: Cash Amount:
6.Total Project Cost: $ ,3��7 ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
G 1 Ili l#can tQr ( ti License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
`fS Fonio� �
No.and Stree1t/ Ty a Description
Unrestricted(Buildings up to 35,000 cu.ft.
( R Restricted]&2 Family Dwelling
Cityfrown,State,ZIP M Mmonry
RC Roofing Covering
INS Window and Siding
SF Solid Fuel Burning Appliances
_Zwsr. I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) tCi
(I q- (1 ti r/l�l t-., HIC fRegistration Number Expiration Date
HIC Company Name or HIC Registrant Name
I f C- ( C tQ r iz.
NLL�an''d Street Email address
L,e`, a L..r•y+- (11Yz 2—
Cityrrown,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 ..........Ek 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 A/j�tA,/nr1 t„%
to act on my behalf,in all matters relative to work authorized by this building permit application.
COw l�tsa�f ,r4-t�-e bS _ /0 -t -/S�
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.
-- - � k - 7- ems
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
.i.vw.mass.eov,'oca Information on the Construction Supervisor License can be found at w%vw.mass. ovf /dns
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"