27 BRIDGE ST - BUILDING INSPECTION CK,44 9
The Commonwealth of Massachusetts , �+
` Board of Building Regulations and Standards W
SALEM
Massachusetts State Building Code,780 CMR
1816 S PR2'�d,'�11�°
7- Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
Q This S.,edjM F+x O,w Use Out
Btmilmjing Poradt I[umber Date P �:
I fango1S ( 77 .
Sviature Dole
51
SEM 1 SIZE IN1FD11MATION
l_ 1.1 Property Address:o?7 pR' k s 1.2 Assessors Map&Parcel Numbers
` I.1 a 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 ft) Frontage(R)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public❑ Private❑ Check ifyes❑
SECTION 2: pROI+ERTYQWNERSfiIP'
2.1 Owners of Record: ,Sg /�i¢ 61976SUDITN HEA(V I G st�RhN,
Name(Print) city,
a7 A21W ST — S77 Email Address
No.and Street Telephone
SECTION 3:DESCRIPTION OT PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.13 Number ofUnits_L I Other Specify: /11FAytAi?A7z0il
Brief Description of Proposed Work:
�nftUlRr f}77-1C + EXTEk[OA Ct/ALLS L(117W 14L69)k CiLLULOSE
SECT14DN 4:ESTE ATED CONSTRUCTION COSTS
Estimated Costs: Officialuse Only
Item (Labor and Materials
1.Building $ d➢ 0 t? 1, Bufidlog Permit Fee:$ Indicate how fee is determined;
D Standard Cityfrown Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ Lam' . . -
5.Mechanical (Fire $ Total AB Fees:$
Suppression)
'/ cp (�edc No. Cheek Amount: Cash Amtumt:
6.Total Project Cost: $ 7 q 78. p Paid in Fall ❑Outstanding Balance Due:
: 3-1 (p
Mtn v�> 1013
SECTION 5: C0M$T!RUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-1067 W
B"b 'IM(lfF .- License Number Expiration Date
Name of CSL Holder ` �1
List CSL Type(see below)
45S InwoAI AW AP Yee
No.and street
(�/f}l��.f C ELD /YiA. d I88U' .U unrestricted(Buildings to 33 000 cu.ft.
R Restricted]&2Family
City/fown,State, M Masonry
RC Roofing Covering
WS Window and Siding
/ SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) //O.SOS /0':3b—�6
S -1cM CON TP4G7iA1 G CO . HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
-7Z 9"N6'r0A) T7-
No.an4StreetD" IM, 001/8 Email address
Ci /town ZIP Tel hone
SECTION WORIUR.4°'COMPENSATION U49LLVWX AFMAVIT(ALGJL c:152.§25G(0)
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 ..........Mr, No...........❑
7a OWNER AUTH6RIZA11IMN TO BE CO LETED"N
WNER'S 13869 TOR F R .. INQ.
I,as Owner of the subject properly,hereby authorize S`T/(Cl) CONT/Ltk Tl.UC CO
to act on my behalf,in all matters relative to work authorized by this building permit application.
oj5& 4 �'�i-4
w'
Owner's Name(Electronic S ature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained" this applicatioZ-17 curate to the best of my knowledge and understanding.
Print Owner's or Authorized gent's a(Electronic Signature) Date
S:
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
wtivw.mass.eov,'oca Information on the Construction Supervisor License can be found at 3nMmiass.gov/cips
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"maybe substituted for"Total Project Cost"