80 BAY VIEW AVE - BPA-14-158 ROOFING The Commonwealth of Massachusetts
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Board of Building Regulations and Standards FOR,
CIPMassachusetts State Building Code,780 CR h�ft1N1USE
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Building Permit Application To Construct;Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D to plie
uiIding Offici (Print Name) Si re Dare
SECTION 1:SITE INFORMATION
1.1 Property Adini-I ��r r )0 1.2 Assessors Map&Parcel Numbers
L la Is this an accepted street?y s_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
i
Zoning District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
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1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal Sa4em ❑
SECTION 2: PROPERTY OWNERSHIP' j
2.1 Ow r' f RecoHie
a
MConstruction
City_,State,Z Telephone Email AddressCTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑.Accessory Bldg. ❑ Number of Units Other 17 S 'fv:
Brief Description of Proposed Work:
1
SECTION 4:ESTIMATED C_ ONSTRUCT ON COSTS
Item Estimated Costs: Official use Only(Labor and Materials
1.Building $ JGJ 1. Building Permit Fee:$ Indicate bow fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2..Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ '7 13 Paid in Full 0 Outstanding Balance Due:
•
f SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) i
t
— License umber E.3p" on -
NameofC older List CSL Type(see below)
JSMtre - TypeDescriptionU Unrestricted(Bui! u to s5,000 cu.tt)
R Restrictedl&.2Fami1 Dwelling
IP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
0 1 Insulation
Tele hone Email address D ILn a.L
5.2 Registered Home Improvemet ontrae or(HIC) I 1 .3�
HIC Regtsb'Ganon Number Ex ratio
HIC Com m o H e ' t Nam
No.and St Email address
Ci /Town,State,ZIP Telephone 1
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152.§25C(6))
Workers Compensation Insurance affidavit must be cogipleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the IssuanceA 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)
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 a and accurate to the best of my knowledge and understanding.
-Print enfs gme(Elecnr& is Signature) vDate
NOTES:
1. An O er who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not rqkistered 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
wwa.mass.uov/oca Information on the Construction Supervisor License can be found at i�wr .mass.3a-=: s
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 halfibaths
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''