B-17-942 - 0024 BRIDGE STREET - Building Permit s ' The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards MUNICIPALITY
i Massachusetts State Building Code,780 CMR
,. t F.1 USE`;
Building Permit Application To Construct,Repair,Renovate Or Demolish a !Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Orily
Building Peimrt Number Date App e r
Budding Offc�al(Print Name) Signature Date
-- .,, .. ....t -.
1 SECTION 1:SITE INFORMATION`
Property Address ;.
1.1 P : 1.2 Assessors Map&Parcel Numbers c
. � S s
1.1a Is this an accepted street. yes' no Map Number ti Parcel Number ' N -
1.3 Zoning Information: 1.4 Property Dimensions:
5 IV X>
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) t ' ' ' ; •V t
Front Yard Side Yards Rear Yard r3
Required Provided Required Provided Required Provided ' £
1.6 Wat Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Z9'0- Municipal�I On site disposal system ❑
Check if yesv/
SECTION 2 PROPERTY OWNERSHIP
2.1 Owner'of Record: S
Name(Print) ' City,State,ZIP,
`�—moo o cs ' .' �C "7 . I,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTIO OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ f Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WorkZ:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
1.Building $ S 000 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x 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: $ / G d U ❑Paid in Full ❑Outstanding Balance Due: .
Gt j 2� tM�z l..d^-U QD � .�•
SECTION 5 CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) L� O 8 -a9'7SY y
11
'� GCA G a� C- License Number / Expiration Date
Name of CSL Holder
I List CSL Type(see below)
ak calla St `S to � T e Description
No.and Street
� U` U Unrestricted(Buildings u to 35,000 cu.ft.
u' R Restricted 1&2 Family Dwelling
City/Town,State,'ZIP M Masonry
RC Roofing Covering
n WS Window and Siding
1�ctcv 3c`�al e n 4 SF Solid Fuel Burning Appliances
C o ylCG-,!t NC"{ I Insulation
Telephone Email address D f Demolition
5.2 Registered Home Improvement Contractor(HIC) 17 y S 2k /8
C G,bl nc v\, t I I A/_(,-4. n 1= J),_ C. HIC Registration Number Expiration Date
HIC Company ame or HIC Registr t Name 1� {�
ea.k d1ei, S S�t �- PCGief13agQVJ� &-,cracCo • w.c><
N and Stre t Email address
r ra h�I� �C, at y(�0 97 -�7T—a�G cj
i /Town tate,ZIP Telephone
SECTION 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 f 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
1,as Owner of the-subject propert ,hereby auth rize C�'bw�, LAPk (� >7z� P,.C.
to act o my behalfZin__iq�m//attt��thojk thrized by t is building permit application.
7• t
Prnt wner's Name lectronic Sig tore) Date
SECTION 7b:OWNER'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 in this application is true and accurate to the best of my knowledge and understanding.
Alw rac-17CJh, &b/.4 U K"Ll LU" V TI—C
Print Ownerkd or Authori ed 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. og v/oca Information on the Construction Supervisor License can be fourid at www.mass. og v/dns
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"