21 BAY VIEW CIR - BPA-15-947 REPLACE DOOR �fq o s1
The Commonwealth of Massachusetts
°"4 Board of Building Regulations and Standards RECE)��ER�� OF
Massachusetts State Building Code, 780 CNOVECTIO�AL SALEM
Reviseg4,lfar 2011
Building Permit Application To Construct,Repair,Renovate Q�pc sha IIt Ub
One-or Two-Family Dwelling j �9 Jt,
_ This Section For Official Use Only
•••� Building Permit Number: Date/Applied:'
I _ 2UyyN, XVf�u..:
` ^ Building Official(Print Name) : .Signature - bate
SECTIONA:SITE INFORMATION
t 1.1 Property Address: - 1.2 Assessors Map&Parcel Numbers
_C21 4644 U"-5k4 e,f�
Lin Is this an acce�reet?yes �no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
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 system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'.
2.1 Owner'of Record: L I Mr:t�z-n tJl
Name rint) City,State,ZIP
C
No.and Street/ �r Telephone Email Address
SECTION 3-DESCRIPTION OF PROPOSED WORW(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: C
1 F.v/wr
�-taG
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:abor and Materials Official Use Only
1.Building $ " 000 1. Building Permit Fee:$ indicate how fee is determined:
2.Electrical $ ,^ ❑Standard City/Town Application Fee
❑Total Project Costa:(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ - -
4.Mechanical (HVAC) $ List: '
5.Mechanical (Fire $ _
Su ression Total All Fees:$
Check No. .Check Amount: Cash Amount:
6.Total Project Cost: $ QJO ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
t2j PS3 •zc-�;�
1, Awc,—, - 4 License Number Expiration Date
Name of CSL Holder
L1 /� List CSL Type(see below)
No.and Street DescriptionC2Gtv� Gr.AI— (�/t�Z R Unrestricted(Buildings u to 35,000 cu.ft.
Restricted]&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered(Home Improvement Contractor(HIC) 7 V
R� �14 kf ay �Ly J HIC egis Expiration Date
HIC ComRRany Name or HIC Registrant Name
I/f f�nlA� /20
N.A and Street Email address
tilt��i/rl y�g— L i5 �7F•?1X-71'4f
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(14LG.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 ..........Qc, 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. �+
Print Owner's Name(Electronic Signature Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 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:
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov,'oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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"