B-17-330 - 0004 BRADLEY ROAD - Building Permit $ 2-8 01
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The Commonwealth of Masai tussC$ '_A R t '
Board of Building Regulations and Standards CITY OF
" Massachusetts State Building C Q SALEM
I i I7 A 10. 5 Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only '
Building Permit Number: Date A lied:
Building Official(Print Name) Signature Date {
t SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
!y 644DL ;4�--S/ R040
�(1 1.1 a Is this an accepted street?yes no Map Number Parcel Number
t�1L11. 1.3 Zoning Information: 1.4 Property Dimensions:
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 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
A-1,/4®,92 A4&Z:-5 Gyccle2
Name(Print) City,State,ZIP
No.and Street QJ Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) .
New Construction❑ Existing Building Owner-Occupied P( Repairs(s) ❑ Alteration(s)JZ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: r�
Brief Description of Proposed Work2: ;Z'A�STj9
U /&/y G A OO,-n _ r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 3 9� 1. Building Permit Fee:$ Indicate how,fee is`determined
2.Electrical $ i ❑Standard City/Town Application Fee
0-Total Project Cost3.(Item 6)x multiplier x.
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ es:Total All Fe '$
/�l Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 7 50 ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
Cityfrb4m,State,ZIP M Masonry
RC Roofing Covering
F4 c,l 0,01V-4 Tt C WS Window and Siding
y� SF Solid Fuel Burning Appliances
/7 S31 J1d mw00 Cbpn I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
0 93 q �T2 r
�Ms HICgon Number Pxpitation Date
HIC Company Name or HIC Registrant Name
o?
No.an Street Email address
Ci /T n,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.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 ..........ZI No...........❑
SECTION 7a:OWNER AUTHORIZATION'TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize P/1 tfl—
7,0,
ehal , all ers relative to work authorized by this building permit application. `
Ig � �• /
Prin wner s (Electronic Signature'r Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By enterin my name below,I hereby attest under the pains and penalties of perjury that all of the information
co ine is r . n i � e urate_to best of my knowledge and understanding.
�13 H5!511 s al
Pnnt Owner's or Authorized Agent'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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
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"