80 BAY VIEW AVE - BPA-13-720 _ The Commonwealth of Massachusetts FOR
b Board of Building Regulations and Stand ds MUNICIPALITY
Massachusetts State Building Code,780 C h edltap�7i +/ USE
f� u Building Permit Application To ct,Repair enovate Or DelndItsha Rev sed January
• I One-or o-Fa, 'ly ling 1,2008
This a Official Use Only
Building Permit Number: Date Applied:Signature: w /�a
Building Commissioner/ or of Buildings Daze
SECTION 1:SITE INFORMATION -
1.1 Property Addr 11 AssessorsJl4ap i&£a cfl�Nl4m erst �li
�O Ic7a / Au4—
1.1 a Is this an accepted s eet?yes_ no Map Number .. Parcel Number -
13 Zoning Information: 1.4 Property Dimensions:
- Zoning Dfstriet Proposed Use - •Lol Area(sq ft) Frontage(11) _
1.5 Building Setbacks(ft) -
Front Yard Side Yards "- Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.GL c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Muni al❑ On site disposal system ❑
Public❑ Private❑ — Cbeck if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1
Name(Print) Address for Service:
Signature Telepbone
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) .
New Construction Cl Existing Building❑ Ovmer-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ JAcceworyBIdg.0 NumberofUnits_ Other ❑ Specify--
Brief Description of Proposed Work' G-� Sea
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only -
Labor and Materials -
1.Building $ 1 Building Permit Fee:$ . -Indicate how fee is determined:
❑Standard Cityffown Application Fee _
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier '„_ _
3-Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $ Total All Fees:$
Suppression) -
Check No. Check Amount: Cash Amount: �
6.TotilProject an
Cost: $ _200- 06 ❑Paid in Full ❑OutstandingBalceDue: . -
SECTION 5: CONSTRUCTION SERVICES - --
SJ Licensed Construction Supervisor(CSL)
License Number ! Expiration Date
Name of CSL-Holder
I�ttWg Jt 5k List CSL Type(see below)
Address _ Salem MA 01970 Type Description
U Unrestricted(up to 35,000 Cu.Fr_)
Signature R Restricted 18,2 Family Dwelling "'
M Masomy Only
RC Residential Routing Covering
Telephone �y WS -Residential Window and Siding - -
�� SF -Residential Solid Fuel Burning Appliance Installation
D Residential Demolition - -
5.2 Registered Home Improvement Contractor(IHC) � f
HIC Compan Registration Number
hl I2 IeffPreDµygp
Address Salem lA 01970 ( ].� 7y y$(Y� Expi. ion Date
Signature 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 .......... No...........❑ -
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize P, r` �a J ,�t.l to act on my behalf;in all matters
relative to work authorized by this building permit application-
Signature of Owner Dine
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, tom!', r� K2—�✓!7 ,aslOwner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf k
�/_� I�KGvr!
Print Name -
Signature of OOmer or Authorized Agent Date - -
(Signed under the pains and penalties of '
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
prograin or guaranty fund underM.G.L.c. 142A.Other important information on the IBC Program and -
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110R6 and 110.115,respectively.
- 2. When substantial work is planned,provide the information below: -
Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Numberofbedrooms -
Numberofbathrooms Number ofhalf/baths -
Type of heating system - Number of decks/porches
Type of cooling system Enclosed Open -
3. "Total Project Square Footage"may be suhstituted4or"Total Project Cost"