14 BAY VIEW CIR - BPA-11-729 REMODEL 2 BATHS ON 2ND FL a nce Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
t ,n OF SALC:M
Massachusetts State Building Code, 780 CMR, 7 edition
"1 t Rcrixed Jauruurr
Building Permit Application'ro Construct, Repair, Renovate Or Demolish a
One-or T1 umily Dwelling
This -ecti n For Official/Use Only
Building Permit Nu ber. Date plied:
Signature: '/ —(.ec
Building Cummissionco1nspvclor of lhqdinyl Date
SECTI 1: SITE INFORMATION
81.1 Propert Address: / 1.2 Assessors Map& Parcel Numbers
� PU f 2 n p 2
I.la 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(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Require) 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'? Munici al❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ F F y
SECTION 2: PROPERTY OWNERSHIP'
Owners of Record: / `
e Pnnt) JJress for ervic ' -_ � —
Signature telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
n_ it
SECTION 4: ESTIMATED CONSTRUCTION COSTS Ho
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6).x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S 000 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) n -7 2/�
( /
p License Nwnt+er lixpimuon ate
Name ul'CSI.- I lolder List CSL l'rpe(see below)
�� �� vtac Description
Address U Unrestricted(up 10 35,000 Cu.Ft.)
R Restricted I Xc? Tamil Ue-ellin
Signal e M I Masonry Only
RC Residential Rooting Co%erin
Telephone WS Residential Window and Siding
SF IResidential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition //
5.2 Le istered Home Improvement Contractor(HIC) / ') Feel � -
I6 VMl Ffru.�Ild" !—
Registration N be
I IIC Company Nmne or tll(h'R��t Name ( I
Address
L.xptmtton Dale
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
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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, as Owner or Authorized Agent hereby declare
thatat thments and information on th foregoing application are true and accurate,to the best of my knowledge and
behalf.
print Names �� ^ )�
Signature of Owner or Authorize gent Dale
(Signed under the pains and penalties ofperjury)
NOTES:
I. 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
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110,116 and 110.115, 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.) Ilabitable 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 Fitt"Total Project Cost"