3 BEDFORD ST - BPA-12-454 SHED —— ----- The C'onunonss'eahh of Massachusetts
Board of Building Regulations and Standards CITY OF
M y, assachusetts State Building Code. 780 CMR SALEM
Hrrisrd.l Grr'lll!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tuvo-Family Um ellhnif
This Section For Official U.ie Only
Building Permit Number: ate A plied:
131111ding 011icial(Print N;une) t ( U0
SECTION I:SITE INFORMATION
I.1 Prop ty Address• 1.2 Assessors Alop& Parcel No ers
3 13e=drortc� S i
L la is this an accepted street?yes no_ bhtP Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Prnposed tl c Lot Area(sq It) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.§Sq) 1.7 Flood Zone Information: 1.8 Sewa D/tsposal System:
Public Private❑ Lone: _ Outside Flood Lune? Municipal ;On site disposals)
Check if es®� -stem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record: 1
pia„ , S 1/ i�e�tS 94- 4. 1'h4- 01570
Name(Print) City.State.ZIP
3 477k-W6 ;DD64VIS6a7O ® ,rceti
Nu.and Street Telephone Email Addmss
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ E. isting Building❑ Owner-Occupied ❑ Repairsls) Alteralion(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units__J Other ❑ Specify:
Brief Descrip 'ono Proposed Work: c
C WW
9 s 0+
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
I Labor:md ..\latrrialsl Y
I. Building S L Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard CityTown Application Fee
❑Total Project Cosl'(Item 6)s multiplier
3. Plumbing S Other Fees: S
4. Mechanical III\':\('1 S List:
5. \lechanical (Fire .__,_-- _- --------
Su„ressiunl S Turd :111 Fees: S_ ___ --------- .
t,. Total Project Cost: 5 ('heck No.
13 Paid in Full 11 Outstanding BuLnce Doc:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Lionse Number.____ ._._ I xpiralion Date
N:unc al l'Si. I?older
List C'SI.
.I.)PC Description
No. and Street
U I htrcsirictcd(IIuilJin�s tip u, 157000
__ R Itcstricicd IR? Family D%wilin
C'it%i lasso, tilalc.LIP NI Nlasonry
RC Rtwlin C'ovcrin j
WS Windm%wd Siding
SF Solid Fuel Burning Appliances
I Insulation
Telc hone 19nail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Rcg,,tr t on Numbcr lispirutio.. Dale
I IIC Connpan) Nwnc or I IIC Registrant Nance
No. mid Street Email address
City/Town.State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 4 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? es .......... ❑ No•.....•••.. ❑
ASEN 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
SAG NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
rop y,hereby authorize
t s relative to work authorized by this building permit application.
ic Signature) 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.
Print owner's or:Nuthorived Agent's None(Electronic.Signature) Date
NOTES:
I. .\n Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program).will no have access to the arbitration
program or guaranty tund under I.G.L.c. 1 q2A.Other important information on the HIC Program can be found at
ttst,t ,,.i Information on the Construction Supervisor License can be found at
2 \\'lien substantial twrk is planned, provide the information below:
Total flour area(sq. n.) -._(including garage, finished basement'nttics,decks or porch)
Gross li%ing area(sq. tl.) - - Habitable room count
\unnbcr of fireplaces___. ._ ..._ Number of bcdroonte _
Numherol'bathroonns --- —_-.. . - -- Number ofhall'halhs
Number of decks, porches
I\pcoI,coo I ill gi)slem _ - I'.ncloied Open -
}. total Project Square Foomec snag he substituted fir-Fotal Project Cost-