B-17-555 - 0004 BRADLEY ROAD - Building Permit s cr 4`�oos
The Commonwealth of Massachusetts t x r..
Board of Building Regulations and Standards C�Ii 1n Massachusetts State Building Code,780 CMR �Q f 19 SALEM
Avisgd Irl 2011
(� Building Permit Application To Construct,Repair,Renovate Or Demolish a
U 1 One-or Two-Family Dwelling
Thts Section For Qffictal a Only,
1
B"ding Permtt Number„" Date„ p77
liedXc
�' Building 0ffid (Print Name) Signature Date
1 „
" SECTION 1 $ITEINFORMAT"ION
1.1 Pro erty Addres • 1.2 Assessors Map&Parcel Numbers
�d. sl�
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1.1 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(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:
Zone: _ Outside Flood Zone?
Publi Private❑ Check if yes❑ Municipal On site disposal system
SECTION" 1. PROPERT'Y OWNERSHIP'„
21 rner of R ord:
rint) City,State,ZIP (�
No.and Street Telephone Email Address
j SECTION 3 DESCRIPTION OF PROPOSED;WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units 6Aer Specify:
rief Description of Proposed Work2: { F'
SECTION 4.;ESTIMATED CONSTRUCTION COSTS F
Item Estimated Costs: Official"-Use Onlyxx`
Labor and Materials
1.Building $ "41 Building Mini Fee $ Indicate how fee is determined
2.Electrical $ ❑Standard Ctty/Town^Apphcafton Fee
❑Total Project Cost(Item 6)X multtplier x
3.Plumbing $ 2 Other Fees $
4.Mechanical (HVAC) $ Ltst
5.Mechanical (Fire $ Total A11 fees:$
Suppression)
Check N_o Check Amount Cash Amount
6.Total Project Cost: $
❑Paid'in Full ,, „ ";❑OutstandtngBalance;Due :
i
SECTION 5 CO !ON
SERVICES
5.1 Construction upervisor License(CSL) M-10A 97 Z 1J-q 11-7
License Number Ex iration Date
Name of CSL Holder f '
List CSL Type(see below) (/I�
Desch h
and Street ,p on
^` U Unrestricted(Buildings up to 35,000 cu.ft.
City/C fate ZIP Y V Restricted 1&2 Famfly Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
1 SF Solid Fuel Burning Appliances
I Insulation
Telephone m 1 addres , D Demolition
Rlgistered Home 114rovement Contractor(HIC) UUM I 3 f Late'
HIC Registration Number Ex ation
mpany ame or e C Registrant Nam
►5 5 o I- - M UAL -' iW la b ram,
d tree ! I f ��� I mail address
Ci /To ,State,ZIP J� / 7 Telephone
SECTION 6. WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L c 152 g 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 AUTI3ORIZATION TO BE COMPLETED WHEN
OWNER'S AG ENTOR-CONTRACTOR•APPLIES FOR BUILDING`PERIVIIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized b i building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:'OWNER''OR AUTHORIZEIJ AGEN..T DECLARATION ,
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
containeM' application is true and acgwate to the best of my knowledge and understanding.
/-7
Print Owner's or A thorized Agent's Name(Electronic Signature) Date
:NOTES
1. An Owner who Vobtains fa 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/des
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"
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Initial Construction.ControLDocumentl
i; �' To be submitted with the buildin17 permit a lication b 'a
( b Pp Y. i
Registered Design Professional.
for work.perthe8"'editronofthe
Massachusetts State T3uilding C ode;:780 I MM Section W7
,.f
Project Title: T I)atc
Property Address
Project:"Check:one or both A.S.applicable New construction 1':S sting Construction
Pi jeci description: —A� ow_$.l!L.S" (a1!YI,I A
Sa
�.
-.........
Kam: Iv1A.R'egistratioti Number wt QExpi on date: ,an a.raU tl l:
re�iatiicl clesi ii pro essional, and 1 hake re aicd or.dicectl su erg i ed the re aiatioii of alldesu n"' tans;
a P f P P Y P p P, g
computations and specifications conceirting:
[ ] Architectural [ ] Structural [ ] Mechanical
[ j Tire Protection [. ] Electrical [�j'Other (Q.D
_ /1
for the about named project and1hat t i'alit best of my knowledge,inforinatioii,and belief sucli,plan`s,"coinput4itians and; t'
spccitications'i ieet the applicable provisions of the,. ssachusetts State Building Code,'(780.CMR),and accepfed
engineering practices for the proposed project. ('understand and'agret that t(or;niu designee)shall perform the necessary,
professional services and be present on the construction site:ona'regularand periodic basis to
l. Review,for conformance to this;code and the design'conce... shop diai sings,samples and other submittals by the
contractor in accordance;with the requireurients of the construction docrments "
2. Peporm;;the.dt forsregistered;design professionals irr780 CMR Cliaptei 17,:as applicable.
present at intervals-appropriate.tathe stage of construction to:become generally fartiiiiar with ilif pro cess and
qualit y:pf the work andao deteriiiP. if the.—ork is bring pti forc ed in a;nianner conststent with> he approved
constriction documents and th s-code.
mn
Nothing;in thi"s docinnent relicv;es the contractor of its responsibility regarding file provisions 6080 CMR 107.-
When i,equured by the btiilding official,I shall subunit field/progress repgrts(see-item .together with pertinent;.
coniuments, in a Orin acceptable to the building official.
O.pon coinpletion of the Mork,]':shall subib it to the building official a`Fi'nal Consfm6ion Controt LDocu iient-
Enter in he space to theright a`,'uet'or:
1.
electronic signatrsre and seal
Buildinb Official Use'Oi4
Bifiljin;Otfi6ial.Niime. Penn
ycrsron 06_I t_2013