B-17-394 - 0137 BRIDGE STREET - Building Permit �3 -7
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The Commonwealth of Massachusetts .
Board of Building Regulations and' q P 12, 5 q CITY OF
WMassachusetts State Building Code, SALEM
T Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OffiqjaKJse Only
1 Building Permit.Number: Da Appliedt
nBuildin Official(Print Name) Si ature . L
Date
h SECTION 1:SITE,INFORMATION
1.1 Property Address:1 �� r► 1.2 Assessors Map&Parcel Numbers
I.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:
Public❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownspi of Record:
Name(Print) City,State,ZIP
No.and Street V Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR W(check all that apply).
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) E Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: '57krip r f 1
S Ar-e t S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
;.
Labor and Materials .
1.Building $ 0 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard CitylTown Application Fee
❑Total Project�Cost3(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: $ l Q ❑Paid in Full ` ❑Outstanding Balance We. "
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License NNumber idn Date
Name of CSL Holder
9 SO � ��__ __ 9 ' : List CSL Type(see below) '
Noland Street Type Description
U Unrestricted Buildin s u to J5,000 cu.ft.
R Restricted 1&2 Family Dwelling
Cityll'own,SAte,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Bunting Appliances
J I Insulation
TdAephone Email address D Demolition
5Z Re istered Home Igrovement Contractor(HIC)
rr r J ,C.�Z r� HIC Reegistration Number Exp4atiah Date
Cmp N 1�'_1� )tJ 1a t�4 .
NN Street Email address
�a M� o���y �7����u 7��
Ci /Town,State IP Tele one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.4c.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..........JO No...........❑
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SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR'APPLIES FOR BUITDING PERMIT .
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I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print O is N e I ctromc Signature) D to
SECTION 71: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.
Printor Authori ed ent's Name(Electronic Signature) 10ate
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.mga&.gov/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"may be substituted for"Total Project Cost"