31 BENGAL LN - BPA-2010-4 SLIDING PATIO DOORS The Commonwcalth of Massachuscus
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR. T"editionja *00MM1400
Building
Budding Permit Application To Construct. Repair, enovate Or Demoli
One- or Tit o-FWn/ll'Dtrrlli g
This Secl^For t ial se Only
Building Permit Num c pplied:
Slgna Nre: I
Building Commtsstoner/Inspector of Buildings Doc
SECTION 1: SI E INFORMATION
1 1 Pro y Address: + 1.2 Assessors Map& Parcel Numbers
±24
1.I a Is this an acce ed street'!yes no Map Number Parcel Number
'
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage ill)
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.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private Check if esI3 P Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow 'of 4 Record: � q lK
Name(Print) Address for Se Service:� S _ J 0 tq
Signature Telephones
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) Alteration(s) O Addition O
Demolition O Accessory Bldg. O Number of Units_ Other O Specify:
Bn Description of Proposed W_o .:
A s"f �Jt, 6. B c9�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OfRclal Use Only
Item Labor and Materials
1. Building f 1. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)x multiplier x
J Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
c Mechanical (Fire S Total All Fees: S
Su resslon
/"�� 1v Check No. _Check Amount: Cash Amount:_
6 Total Project Cost. S ❑ Paid in Full O Outstanding Balance Due:
A
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Constructio//n^�Supersisor(CSL) C7—C l i `7
" �lJa-� P`ts.Le/ L¢ense Number Espuwion Date
N44M of CSIder List CSL Type bet Mow)
l�
Addrrss RDRcsidential
d � ritrSignature .-•(/`� nuTclephon nuStdmual Sohd Fuel Buual Demolition
3.2 R s erect Home Improvem at Cont actor(HIC) f(�� 6
t e P �y4�S C Cc%
HIC Company e or CIC'Regt t Name Re istiation lumber
Add
e 79-1 G `,S S —Ooo Expiratio Date
Signs « _ Telephone
SECTION :WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. e. 152.1 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..........O No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, `/�^^G ¢ e �� as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of OwWer or Authorized Agent `•'r/`T�,_ Dase 1
(Signed under the pains and penalties of perjury
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 gjfl 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 I IO.RS. 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 halfbaths
Type of heating system Number of decks/porches
Typeof cooling system Enclosed .Open
3 "Total Project Square Footage"may he +uhwrtuted for"Twal Project Cost"