11 BERRYWOOD LN - BPA-14-81 PATIO DOOR The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
" Massachusetts State Building Code, 730 0411 SALEM
Revised filar 201/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
[hisSedioriFbrOfficial WO'*.'
Building 1'armit Number: - Oate.A p "
Building Offleial(Print Name) fora. Data
SECTION [:SITE-INFORMATION
1.1 Property Address: M/ A9Ca 1.2 Assessorarcel Numbers
l.la Is this an accepted streetT y s no Nfap Number Parcel Number
1,3 Zoning Informatlon: 1.4 Property Dlmenslonsr
Zoning District Proposed Use Lot Area(sq R) Frontage(it)
1.5 Building Setbaclts(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:(M.O.L c.40,§14) 1.7 Flood Zen Ioformatlont 1.3 Sewage Disposal Systemt
Public❑ Private❑' Zone: _ Outside Flood Zone?Check if es❑ Municipal❑ On site disposal system ❑
SECTION Z PROPERTV'MV4VERSFDP! '.
2.1 Owner! f ecord:
r
Name(Print) City,State Z1P
No. and Street Terdphona Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW'6heck all, ' !apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)al Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ NttmberofUnita_ Ot r ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIi4 4TED CONS RUCTION C STS-
Rem Estimated Costs: p(Rcin) Use Only..
Lu6orand Materials y
I. Building S 1. Buildihq PermitFee:3 Gfdicate how fee is determined:
3. f rctrirtl (?Standard.CitylfawnApplication Fee.`
❑'rutal Project Cash(ftem 6)x multiplier x
1. I Iurnb1 .4 S 7. Other Fits: .S
1. ,\I_chanical (IIVAC1 S List:_
i. \Iceh.wic.d (Pin:
1'01.11 All Pces: i
-
� " I'(,tai I'rnjcet ( 'n;t ) � f (� I'.iil in Pull ❑ thd;t:m.lin, Ifal.uie.: I!uu: -----
Sf?crio N 5: CO;VS'fRUCTIUN SERVICES
5,1 Construe ' n Supervisu License(CSL)
Licensense Nw� — Cxpir, oWit
NamC of CSL 11o1d List CSL type(see below) --
-�— rypa Description
No. ;nd S Celt {` U UnrCstricted Duildin s u to JS,000 cu. R.
��Wr it Restricted I:e?Famil Dtvelllin
City/town,State, ZIP INt \I:uonr
RC Rootin Covent
WS Window lindSidin
SF Solid Fuel fuming Appliances
I Insulation
uaddressp Demolition
i 1'ele hmta Email
5.2 Registered Hume Im roverne t Contsac HIC)
Ilic liegistnttion umber Exp' tttt a e
111C ' Na e r Cg'' a
Email address
No.aniijz
Ci /Town State LIP Telephone
SECTION 6: WORKERS'COdIPENSA'TION INSURANCE AFFIDAVIT(M.G.L.c. 152. 9 25C(6))
be co ted and submitted with this application. Failure to provide
Workers Compensation Insurance affidavit must
this affidavit will result in the denial of the Issuarcpicifthe building permit.
Signed Affidavit Attached? Yes..,....... No...........17
SECTION 7a: OWNER AUTHORIZATION TO OE CO NIP LET ED WHEN
O W NERIS AGENT OR CONTRACTOR APPLIES FOR IM ING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this uilding permit appl cation.
it
Print Uwn¢r's Nome(Elaetianic Signature)
SECTION 7h: UWNERt OR AUTHORIZED AGENT DECLARATION
By entering my naina below, I hereby attes and the pains all penalties of perjury that all of the information
containe ut tis applicat', n is true and ac urata o It best o y k wledge and understanding,
I+filtt Owllcr's Jf Authurited:\gau's N.une Date
Elatr 11 Signaat O
NOTES:
1. An owner who obtains a building permit to do himher own work,or an owner Who hires an unregistered cuntractur
((lot regismred in the ilonta Improvement Contra (HIC) Program), will tan hava access to the arbitration
pro III or guarunty fund under LM.G.L. c. 142A. other important information on the H[C Program can be found at
ttWW nrt,s.euv%aca Information on the Construction Supervisor License can be found at atvtv.was
s.�ylt_,Ilgt
t \Vhen submantinl Work is planned, provide the information below:
I'utal flour area(+q. lt.) (including garage, finished basemenVattic;, decks or porch)
1labitablC nnan count --
lro;; living:irea(;y. tt.l Nun:bar of bedrn,nns
------- — NuuIl+CrofhalE'batlts
�tuinhcr of h.uhnanns -- --------_.
Illihi(Ut ,IJi h.i; I`tf 1'l ICi __-
I .I,e „f h..uim; ;yitcnt --- - Fuclo;cd I Ipen
� ..I .,I d I'n q:rt � pi ir•� I� „ LI :�" ul.ry he all+artnt:J t,a It.11 I'ngr,t l ud- -