128 BAY VIEW AVE - BPA-16-1382 REPLACE 20 WINDOWS f 238' CKIg5cli
16
k ,, The Commonwealth of Massachusetts 'c UN VL e <
W Board of Building Regulations and Standards C1TSALEM
to '. d�� y t = Massachusetis8tate Building Code, 780 CMR IOIb NOV2 .Rl�se�tlk(r(�0l!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Onl
Building Permit Number: Date Applio;
Building Official(Print Name). :. Signature - - Date
SECTION 1:SiTE INFORb1ATtON
1.1 Property�ddr�ss r`I p 1.2 Assessors Map&Parcel Numbers a t
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy Il) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Reyutrcd 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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if ycsO
SECTION2: PROPERTY OWNERSHIP!'
2.1 01 rt of Rf)cord
/
iSolvf.(rl 1 tam '1'�t
t�tlme(Pnn
W ������ City,State, I
rce
� -
No.and Slt a ephone � Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(cheek 01 that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 131 Alterations) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed\Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building S I. Building Permit Fee:$ dicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
{. �Icchvtical (HV;1C) S List:
5.Alxhanical (Fire S 'Total All Fees:S
suppression)
Check No._Check Amount: Cash Amount:_
6, 'rutal Project Cost: S 7J ❑Paid in Full ❑Outstanding Bakince Due:
`'Y1f�tL� 1� IlIZB
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
v� License um er s r ion Date
Namc of CSL[foll�d�����t��ynl '� List CSL"type(see below)
Ua AkLk 1 040 Typo _ _ . _ Description .
No.and Street -
U I Unrestricted Duildin s u -to 35,000 cu.It.
4.�"M K, R Restricted I&2 F:unil Dvvellin
City/ibwn,State,ZIP M Masonry
RC RootingCoverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered If me Improvement Contractor(HIC) ''
H . '1C R g slration Number E non Date
HIC Company Name or II IC Keg]StrJltt Name
No.an eet Email address
,RI or"6
Ci /Tuvvn State ZIPTele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.G c.152.¢2SC(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...........
CI
SECTION 78:01VNER AUTHORIZATIONTO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize �nl�
t9 act on my behalf,in all matters relative to work authorized by this buil tng permit application.
� 1
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWN ERt ORAUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
coZ"e"'s
this a plication is true and accurate to the best of my knowledge and understanding.
y�
Pu or Aut t razed Agent's Namc(Elecuonic Signature) Date
NOTES:
1. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will nut 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
�eww mass cov:'oca Information on the Construction Supervisor License can be f'ounii at wvaw•.tnass.sov:'Jns
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. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rype orcooling system Enclose) Open
3. Total Project Square Footage"may be substituted f'or"'rot:d Project Cost"