24 BENGAL LN - BPA-12-841 REPLACE 2 PATIO DOORS The Commonwealth of Massachusetts
11 Board of Building Regulations and Standards CITY OF
h' � Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied:
Building Official(Print Name) Signature V Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel N mbers
I.l a Is this an accepte treet?yes no Map Number rarcel Number
1.3 Zoning Information: 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:
Gone: _ Outside Flood Zone?
Public ❑ Private❑ Check it ves❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wnert of Record:
Ve+,er Smolt el^ 5g1grh, mt9 01110
Name(Print) City,State,ZIP
a4 Benue L arl� y78-7�fb-W5
No.andNo.and S� 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'': q y
o Sifu s.\ tuorK 6,ethc, w
off _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 51 O ?O 1. Building Permit Fee: $ Indicate how fee is'determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑ Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ O�
4. Mechanical (HVAC) $ List:-
List '�(,�.� C.�J! I
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 41 gl�, $O 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 8 2 f 93 la 4 t3
- didwel ell* License Number Expiration Date
Name of CSL Holder
5 136561 4.
List CSL"I ype(see below)
�
No. and Street Type Description
ev,i'2kr+ ma olg70 U Unrestricted(Buildings up to 35.000 cu. R)
R Restricted 1&2 Family Dwelling
City/Tow'nS,I,aU,teGRIP M Masonry
RC CoveringRoofing Window
WS Window andndSiding
Sr Solid Fuel Burning Appliances
478-7ys—,�Cy 1 Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) e
o 4m,) Domes C.en-[Te . 14 T t 8� 1 rat la
L
HIC Registration Number Expiration Date
HIC Company Name or HIC R66•gistrant Nap�7e
u-59 Turnpike f- 5 ,11L Idb
No.and Street O 11 11-7 417-3sy-a9y6 Email address
City/ 'o"w"n'!State, IP yjaje4 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: OWNEK 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 Owners Name(Electronic Signature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby artest under the pains and penalties of perjury that all of the information
contained ethisC is do i tup and accurate to the best of my knowledge and understanding.
AL 'Kit" Oralore 3 ,�
Print Ownc k'or-lluthorize�dYgent•s Name(Electronic Signature) I I 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 M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.�
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"