17 BAY VIEW CIR - BPA-16-637 REPLACE 1 WINDOW $b� �wvb3o�
ga The Commonwealth of Massachusetts itiii�PEGTI€)#IAi Sii dTY OF
d Board of Building Regulations and Standards
Massachusetts State Building Code, 780 C SALEM
ib JUN I4 A MadMarloll
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use _'7:,
Building Permit Number:
Building Official(Print Name) = s; " Signs . .;�, �; ..- Date .i -'
I_ SECTION 1:SITE INFORMATIONx,
1.1 Property Address: 1.2 Assessors Map&c Parcel Numbers
17 RAY VIFW CIRCI F .33 ^nb OS -0
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 rg ing Information• �f �p J� 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) 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.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑.On site disposal stem ❑
Check if es❑ system
— �SECTION2: PROPERTYOWNERSBIP' ,,.,
_
2.1 Owner'of Record:
DIANA LaMONTAGNE SALEM MA 01970
Name(Prim) City,State,ZIP
17 BAY VIEW CIRCLE 978-745-1016
No.and Street Telephone Email Address
SBCTION 3:DESCRIPTION OP PROPOSED WORKS(check all that aPP1Y) a``^.
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.O I Number of Units_ I Other Specify:_ REPLACEMENT
Brief Description of Proposed WorV.- REPLACE 1 WINDOW- NO STRUCTURAL CHANGE
SECTION 4 ESTIMATED CDNSTRUCTION COST5
Estimated Costs: -
Item and Materials Official Use Only
1. Building $. 8,444.00 1 Building Permit Fee $ Indicate how fee is determined
2.Electrical $ ❑Standard CitylTown Application Fee--, r.:
❑To Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees $
4.Mechanical (HVAC) $
List:
5. Mechanical (Fire $
Suppression) Total Al]Fees.$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 8,444.00 ❑Paid in Full ❑Outstanding Balance Due:
M(:aA%_1G9V 1 %,� zv l t (�
SECTION'5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
90125 10-06-2016
JAIME MORIN License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
86 GARDINER ST
No.and Street Type_ `Description
LYNN, MA 01905 U Urr+estricted(Buildingsu to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,Statq ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
508-351-2214 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
170810 ��
RENEWAL BY ANDERSEN HIC Registration Number Expiration Dace
HIC Company Name or HIC Registrant Name
30 FORBES RD
No.and Street Email address
NORTHBORO_MA 01532 508-351-2214
City/Town, State ZIP Telephone
4. SECTION 6 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GlL 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........... ❑
SECTION.Ta OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMTP
I,as Owner of the subject property,hereby authorize JAIME MORIN
to act on my behalf,in all matters relative to work authorized by this building permit application.
SEE AGREEMENT
Print Owner's Name(Electronic Signature) Date
SECTION 7bt OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my qbel ,I hereby attest under the pains and penalties of perjury that all of the information
contained in this is true and accurate to the best of my knowledge and understanding..
6 -Io - /L
Print Owner' or A orized Agent's Name(Electronic Signature) Date
1. An Qynfer 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 find under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass gov/aca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.fL) (including garage,finished basementlattics, decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of haWbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"