B-19-53 - 0012 BRADLEY ROAD - Building Permit $Zlc- C-r-12-W71.,
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALI1
Revised Mar 2011 r
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OfftciatUse Only r
Building Permit Number: Date Applied:
3
Building Official(Print Name) Signa ure , Date•'
SECTION 1:SITE INFORMATION `
1.1 Prope Ad ss 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted stree?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:
Public❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: :PROPERTY OWNERSHIP' '
2.1 OVez! f rd:
few
tom. �
Name(Print)- City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRI'PTION OF PROPOSED WORKZ(check 41 that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)< Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: aj
SECTION 4:<ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only "
Labor and Materials
1.Building $ _ 1. Building Permit Fee: $ �"�,Indicate how fee is determined
❑Standard City/Town Application Fee
2.Electrical $ 3 ..,
❑Total Project Cost 3(Item 6),k multiplier x
3.Plumbing $ 2. Other Fees::$
4.Mechanical (HVAC) $ List: ,
5.Mechanical (Fire $
Suppression) Total All Fees::$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full LL ❑Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
- t l L2
2
License Number Expirat n ate
Name of CSL Ho er
List CSL Type(see below)
1�
No.and Street Type Description.
U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP -r l--� R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
, I Insulation
Telephone Email address D Demolition
s�+
5.2 Registered me Improvement Contractor(HIC)
HIC Registration Number Ex f n ate
HIC Compa ame Registrant Name
No.and S e ttIA Email ad es
No. 11 f)6YI/
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152 §i25C(�)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc the building permit.
Signed Affidavit Attached? Yes .......... 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
to act on my behalf,in all/matters relative to work authorized by this bu ding permit application.
Print Owner's Name(Electronic Sig ature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION „
By ente ' name beJow,I hereby attest under the pains and penalties of perjury that all of the information
co in in is n is true and accurate to the best of my knowledge and understanding.
t O is or KuthoiTzed Aj6 ame(Electronic Signature) Z Ifate
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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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"