0114 1/2 BRIDGE ST - BUILDING INSPECTION rAh T 4
The Commonwealth of Massachusetts 1 '
Board of Building Regulations and Standards !'(//6 pO�Fr
' Massachusetts State Building Code, 780 CMR i2evised M�204
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
1 •� '=
This Section For Official Use Only._-
BwldmgP.e nrt Number.; Date App Ild: _
Bmldtng 0fficral(Pnrit Name)�e,. :•` 1 r -•..`" Sigeaturef.'r �•. - _ -- -- "�
SECTION 1:SITE INFORMATION,
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
114 1/2 BRIDGE ST SAI FM MA 01970 36 0062
1.1a is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
R2 TWO FAM
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 a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private Check ifyesl7 Municipal O On site disposal system El
'SECTION2:,PROPERTY`OWNERSHW'
2.1 Owner'of Record:
BRIAN LITALIAN SALEM, MA 01970
Name(Print) City,State,ZIP
114 1/2 BRIDGE STREET 978-594-1298
No.and Street Telephone Email Address
S[ItON 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building If Owner-Occupied Repaim(s) if I Alteration(s) D 1 Addition ❑
Demolition D Accessory Bldg.❑ Number of Units_ Other g specify:Replacement
Brief Description of Proposed Worle:
RFPI ACF 5 WINDOWS - NO STRUCTURAL CHANGE
SECTIONS:ESTIMATED CONSTRUCTION COSTS._
Estimated Costs:
Item aidloor and Materials t " Offieial'Use Only. '
I.Building $ 7,859.00 I;;,Building Permit Feen$^' Indicate., how fee is determined'
2.Electrical $ O Siindazd City/T6o'vun Appri&don Fee t
13 Total Project Costs(Item'6)x multip&er x
3.Plumbing $ 2. Othei Fees; $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
S ssion Total All Fees:$
Check No.-_Check Amount: Cash Amount:
6. Total Project Cost: $ 7,859.00 0 Paid ur Full 13 Outstanding Balance Due:
8 f 50 MPP I LA�b 10 Stems cs
SECTION'S: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 90125 10-06-16
Jamie Moim License Number Expiration Date
Name of CSL Holder U
Lis[CSL Type(see below)
86 Gardiner St
No.and Street -Iypc_ _ -- _Description
Lynn, MA 01905 U Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
508-351-2214 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 170810 12-23-17
Renewal by Andersen HIC Registration Number Expiration Date
BIC Company Name or HIC Registrant Name
30 Forbes Rd
No.and Street 508-351-2214 Email address
Northborough, MA 01532
Ci /Town State ZIP Telephone
_ S_ECTI_ON 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 OWNER'AUTIIQRiZAT'ONTO BE COMPLETED WHEN_
OWNER'S AGENT ORCONTRACIORAPPLIESFOR-BDII DINC PERMIT
I as Owner of the subject property,hereby authorize Jamie Morin
to act on my behalf,in all matters relative to work authorized by this building permit application.
SEE CONTRACT
Print Owner's Name(Electronic Signature) Date
SECTION;7b:'O-WNEW OWAUTHORIZEDAGENT DECLARATION
.
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this appli is and accurate to the best of my knowledge and understanding.
JAIME MORIN
Print Owner's or Authoi fit's Name(Electronic Signature) Date
NOTES:
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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.goy/dos
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"