3 BAY VIEW CIR - BPA-2010-624 REROOF 1 The Commonwealth of Massachusetts
11JnJ �� Board of Building Regulations and Standards CITY
1,7 Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM
�sZ Revised Junuury
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. loox
One-or Two-Family Dwelling
is SectionF-rOffici seOnl
Building Permit Number: VD Applied:
Signature: 3 ' 23 + Q
Building Commissionq InspectorVB ilif Date
SE N 1-SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
3 �33.aY.Address:
pw C I. tz
I.I 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(sq 11) 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.do,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Name(Print) Address for Service:
9 -1 S. -7 ti 1 3-2---�
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Buildi 4.owner-OccupiedzS4Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':_ o -b- R' R
SECTION A: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
I. Building $ Q Q 00 I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
.Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
6.Total Project Cost: S �..= Check No._Check Amount: Cash Amount:
> ❑Paid in Full 0 Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 09q—I J,:s �� lyti 1t0
TLicense Number Expiration Date
Name ol'CSL-I[older List CSL"Type(see below)
1 `kit Maty S( Qoo ��Y
f Description
.Sdd _ U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted I&2 Family Dwelling
Sigre ore ,ry M Masonry Only
7 Ti 3 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 egistered H e ImprovemenL.Contractor(HIC) 9 O g I
HIC Company Name or HIC R�gistram Nam Registration Number
1 C4 MAI1 S� �on bno�' �_ -2--
Addrcs � 7 Expiration Date
�ti r��
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...........❑
g �I
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , 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.
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1, (ram 6 L_A,— C ,as Owner o Authorized Agent ereby 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 ol'Owner or Authorized A ent Date
Si ncd under the pains an penalties of 'u
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 noI 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 110.116 and I I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"