21 BAY VIEW CIR - BPA-14-457 REPLACE 17 WINDOWS 152- a 1 �2
The Commonwealth of Massachusetts
Board of Building Regulations and Standards a ry OF
Massachusetts State Building Code, 780 CR SALEM
M Reviserl.b/ur 101
Building Permit Application'Co Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D e pplie 1��v --
Building Official(Print Name). -" S gnature D,to
SECTION 1:SITE INFORMATION
I.1 Proper y Address: 0 1.2 Assessors Map& Parcel Numbers
ar�� c/2 —
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(sq R) Frontage(It)
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: L8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyesO
SECTION2: PROPERTY OWNERSHIP"
2.1 Owner[of Record:
Zot L* B4 i
NN nie(Print) City,State, P
�/ �R� rll�� ruz gi7&•)VJ-aJ-n
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item bor and Materials) Official Use Only
I. Building $ a/ Dw) — 1. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Su ression) "Coral All Fees:$
Check No. Check Amount: Cash Amount:
6, Total Project Cost: S L � Ooo 0 Paid in Full ❑Outstanding,, Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) tOS-9y.S3
A)rrltk-iI, License Number /Expiration Date
Name of CSL Holder
List CSL"type(see below)
45-- Fa-'at W's, .
N T Description
o.and Street
4Aq&�U O/ 2 U Unrestricted 2Fai(Buildings a toing cu. ItJ
R Restricted l&2F;unil Dwelling
Cityffown,State,ZIP ibf Nfisonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'tale hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I�7
�j Da_f
Q A— OWOCU. HIC Registration Number Lxpirution Date
IIC Company Name or HIC Registrant Name -
45—FBAI,11— l25
�d..and reet Email address
rs�St G I.rm- D[lL37— o/7b.ZGS•`7�
City/Town,State,ZIP Tele hone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 .........OKINo...........❑
SECTION 7a:OWNER AUT IORIZATION:TO BE COMPLETED WHEN;
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize f AJ 0&14J S
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
G("066 1, ,A, 1'2 --3-f 3
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION-
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 NI.G.L.c. Id?A.Other important information on the HIC Program can be found at
Www.mass.zoy'oca Information on the Construction Supervisor License can be found at www.ma;s."OV111 t-s�
3. 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
rypeofcoolingsystent Enclosed Open
1 `Total Project Square Footage"may be substituted for"Total Project Cost'