128 BAY VIEW AVE - BPA-11-109 SIDING Z' The Commonwealth 01 MaSSachusctis
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C'MR, 7'cJition OFSALEM
Rrvr)rd Jwnrun•
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or rwo-Family Dwelling
This Section For Official Use Only
Building Permit Nu Date Applied:
Signature: �� f 0
Cam- Buildin ummissioner/Inspector of Buildings f}.rte �^
SECTION 1:SITE INFORMATION
1.1 Property Address: v 1.2 Assessors Map& Parcel Numbers
l2 $ Rkv V(•2�
I.la Is this an acre d street?ycs_LZ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
I.s Building Setbacks(R)
From 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 O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check if yesCl
SECTION2: PROPERTY OWNERSHIP'
2.1 Owllertof,Recor. r r)
s1 a l� a 1(' a Lsu K ut&W L 2.� .tS°�-�/ yl e c.y y e?
X Name P ' t� /m4� Addte}s aServic I
Signature Telephone
SECTION 7: DESCRIPTION OF PROPOSED WORK'(check aB that apply)
New Construction O Existing Building O Owner-Occupied X I Repairs(s) O 1 Alteration(s) Addition O
Demolition ❑ Accessory Bldg.O Number of Unib Other O Specify:
Brief Description of Proposed Work% �
•1 Y lA-'1 /� U P t n rY �% S f lit /�!JI M C l/'�F' ,9 4? G r2
a 41)(a S 42 a t1 ✓41 f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Cases: Official Use Only
Labor and Materials
I. Building is I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard Citylrown Application Fee
O Total Project Cost(Item 6)x multiplier x
1. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
ck No. Check Amo n1: Cash Amount:
6. Total Project Cost: S 7 5 D el FX Paid in Full ❑Outstanding Balance Due:
/a
7
SECTION 3: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number I:\pimlion Dale
NJme of u!I l'SL• Ilulder �• G2"1�
List C'SL Type)see below)
f IX-scription
:\Jdress U I Unrestricted u iolS,000Cu.Fl.
R I Restricted 1&2 Family Uwellin
tiiynJmre t� �. M M Only
( 673 U RC Residential Roulma Covering
1'depMme WS f Residential Window and Siding
Resimtal Solid Fuel Burning Appliance In%l2llJ1iUn
sidWSDF Rit i Demolition
EAddi�cl
Imp we tot Contractor(HIC)
- G ✓Z C�u' �25"7 Z' 2<'( ( Registration Number
'Rcgut ll N �J - .-J7 � �f� Etpiralion Date
"felep "t
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.f 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 ..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 5 e P L <f L-s 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.
Signsturcof0wricr Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 ,as Owner 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.
Print Name
Signature of Owner m Authorized Agent Date
(Signed under the pains andperuiltics ofperjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will 01 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R3.respectively.
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 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"