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B-19-26 - 0082 BRIDGE STREET - Building Permit 5 The Commonwealth of Massachusetts 1 ! Board of Building Regulations and Standards CITY,OF � �. Massachusetts State Building Code, 780 CMR Revised Mar 42011 Building Permit Application To Construct,Repair,Renovate Or Demolish a?u�G v One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: lv Building Official(Print Name) Signature Date 1 SECTION 1: SITE INFORMATION 1.1 Property ddress: 1.2 Assessors Map&Parcel Numbers �Z �rr •e L la Is this an a cepted 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 upply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Check if yes❑ C�7Disposal System: Public Private❑ Zone: _ Outside Flood Zone? Municipal On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: nn Name(Print) I o 12,5 1 'U> City,State,ZIP Fa BR/DCe 5-r gORY7734aY 6fiaWfe ,C No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED,WORK (check all that apply) New Construction❑ Existing Building Owner-Occupied fd I Repairs(s) d I Alteration(s) V1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units 7— Other, ❑ Specify: Brief Description Proposed yJorkZ: 1 004:2 Gc"Id PA W-4 o p-1re ZA r 5, y9doo C e5e7' 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 Ut) 2.Electrical $ /� 8, oU ❑Total Project Costa(Item 6)x multiplier J l 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: $�5 �� ❑Paid in Full ❑Outstanding Balance Due: wU,tL_t2E-D TD Mips, SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Cs ash 22y /-/ ' ,1 o76.2© , �u r— License Number Expiration ate Name of CSL Holder ,� / List CSL Type(see below) No. d Street Type Description J � ®/�� U Unrestricted(Buildings u to 35,000 cu.ft.) l Restricted 1&2 Family Dwelling City/Town,Stal ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Z� 9®7 7 MSC $5$6876JCc--/ Conte I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 'P--J JD' n-r-1 HIC Registration Number Expiration Date HIC Compa , Narye or HIC Regis a e / l w wr ®+ 711i11�C $.SB6$7�cto!•�c�.+�. N nd Str t Email address O A Of`16 172 807.55S7 Ci /Town, te,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 of 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 property,hereby author' e 0 004� to act on my behalf,in all matters relative authorized by this building permit application. Ta t /L r,row— I Q Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest unde the pains and penalties of perjury that all of the information contained in this application is 717r t of my knowledge and understanding.` //7 Print Owner's or Authorized Agent's Na a(Ele nic 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. ov/oc�a 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/batbs 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"