3 BEDFORD ST - BPA-13-594 BATH ,v
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
'i Massachusetts State Building Code, 780 CYIR S Mar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use
Building Permit Number:' Date Ap lied:i '
Building Official(Print Name) _ Stgna re _ - Date:
SECTION 1: SITE INFORNIA ION
1. Pr 1.2 Assessors Map & Parcel Numbers
/5y1� S r
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:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:,'PROPERTY'O WNERSHIPl'
2.1 Owner'of Recor / M
A clq? o
Name(Prin City,State,ZIP
4 r' +tj)� �{_t,(rat �� S'( Ci-)?7tA 46K ' qE—)- 1S,6J a L
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORJV' check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: e a rsv rt — i
%Lt3 fi
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only>.,
Labor and Materials
1. Building $ 1. Building Permit.Fee $ Indicate now fee is determined:
❑ Standard.City/Town Application Fee
2. Electrical $ ❑'rotal PItoject Ccst'3 Item 6)x multtpher' x
3. Plumbing $ 2 Other Fees: $
4. Mechanical (IIVAC) $ List: _.
5. \dechanical (Fire 5
Su ression) Total All Fees: .$
Check No. Check Amount: Cash Amount
- 'l'otaI Project Cost: $ 1666, UU ❑ Paid in Full ❑ butstanding Balance Due:
v
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Gepiration Date
Name of CSL Holder
List CSL Type(see below)
No. and Street — Type Description
U Unrestricted (Buildings Up to 35,000 cu. tt.)
R Restricted 1&2 Family Dwelling
City/Town, State, "ZIP bl Masonr
RC Rootino Covcrino
WS Window and Siding
SF Solid Fucl Burning Appliances
I Insulation
"relz hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
HIC Registration Number Expiration Date
FIIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit mast 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 authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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.
�S l/t I �Pn t S I Z� 13
Print Owner's or Autlwrizai:4;ent's Name(Electronic Signature) Date
NOTES:
I. 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. I42A. Other important information on the HIC Program can be found at
aoww.Mass.''oroea Information on the Construction Supervisor License can be found at wwvw.mass.eo�'M-
2. When substantial work is planned,provide the information below:
Total floor area(sq. It.) _(including garage, finished basement/attics, decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of III replaces_. _ Number of bedrooms
NUmber of bathrooms Number of haWbaths
Type of heating system Number of decks/porches —-- --
I}peof coolingsysicim_ _ Enclosed-___ _--_---Open-
3 ;'Total Project SyumLe Footage' may be substituted fox""Taal Project Cost" -- —--------- -.
CITY OF S.ULE.)vt
PUBLIC PROPERTY
DEPAM, [ENT
u.a.aan+r c.sruu.
Vwrae i]e v+wwctor.snaat•su,K Ws�oasens 01•'0
snr.9,w4s.9sss•v.%a r.r r+o.9w
HOMEOWNER LICLNSS EXEM"10M
Pleaw Fsist
Date 13
lob Location 7�e�(bye
Home Owmr Address 1P
Home Owns Telephone
Present Mailing Address u
The current exemption of Homeowners"was extended to include owner-occupied
dwellings of two Units of tea$and to allow such homeowner$ to engage an individual for
hire who dodo not possess a liceote provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Pawn(s) who owns a parcel of WW on which hdsbs resides or Intends to resider on
which there U6 or is intended to be6 a one at two family dwelling, attached or detached
.structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Ofllcial, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "honseowner"assumes responsibility for compliance with the State
Building Code and other applicable bylaws and regulation,
l
The undeniSned "homeowner"certifies that h e un t the City of Salem
Building Department minimum inspectio roc and uirements and that helshe
.vill comply with said procedures and uir
HOMEOWNERS S/GNATLW _
.APPROVAL OF 9UfLDfYG GY ECTOR "
See other side far state code
I
e
CITY OF SAL.EM) -L-�.�RSSACHUSETTS
Iola
BUILD4IGDEP1'NtENT
1'_0 WASH w LIGTON STREET. 3 Ft.00R
TEL (978) 745-9595
KINMERLEY DRISCOLL F.+.C(978) 740-9846
NL-%YOR THOsus ST.PtERRS
DLRECTOR OP PI:BLIC PROPERTY/HCILDLIG CONWISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of iMGL c 40, S 54;
Building Permit f# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
e De,
(name of hauler)
The debris will be disposed of in :
-- `—� (namcof facility)
�5����1
(address of facility)
gnature of permit applicant
date
Jabi n �;d.k