24 BENGAL LN - BPA-2010-930 2 PATIO DOORS i
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
ICY Massachusetts State Building Code, 780 CMR, T"edition OF SALEM
Revised Jururury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 100
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numb er• Date Applied:
Signature: 6��7/l0
Buildi Commissioned Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: ►3EIV&pL G.4,UE 1.2 Assessors Map& Parcel Numbers
�y1.to I o 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(R)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record g�A►(g1A41 �-
���ef s�+2�r ay �� e
Name(Prim) Address for Service:
IN- 7yo
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': ^k- A
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building Is 3 �3 ,S�( 1. 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
. Plumbing S 2. Other Fees: S
4
. Mechanical (BVAC) s List:
5. Mechanical (Fire S
Su ression Total All Fees:S
g,� Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 3� j ❑Paid in Full ❑Outstanding Balance Due:
�� � h � �
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed (Construction Supervisor(CSL) .11 7� 7d
S �er2l�Cvl M 4Cn k-k CTGI License Nr l:tptmtiu Dute
Name ul'CSL•Ifolder List CSL Type(see below) U
s ck� 1� ��. ��+kid vH f Description
:Wdmss I unrestricted u to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwellin
Signaure M Masonry Only
O r7 -7 RC Residential Roofing Coverinit
relephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Rsegbte Home Impro�etngot C�otractor(HIC) ),2 3 7/�
kG dF�H
HIC Comp y Name u(IIIC Regislmnt N —Ile Registration Number
Address c e Eipirdtion Date
i d3-3Qv- 73STi
Signature 'relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
-OWNER'S 1AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I (I e- L ifSL/1 lZ e-`r as Owner of the subject property hereby
authorize Lf-e e- la.�jo.rCr•.c l" to act on my behalf,in all matters
relative to work authorized by this building permit application.
-Signature of Owner Date
II`` SECTION 7b: OWNERit1OR AUTHORIZED AGENT DECLARATION
I, UGS is p.L /-ow-,'S L'I M aL - /'• ,as Owner or Authorized Agent hereby declare
that the statements artrinfornnattion on the foregoing application are true and accurate,to the best of my knowledge and
behalf. W JJ � /)
es(c
Print N� � {�/�6
Signal/ore%f�Owner rAutho Agent Datc �/•.Y
Si ed under the pains andpenalties;of 'u
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 no have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 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.) 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"maybe substituted for"Total Project Cost"