4 BEDFORD ST - BPA-13-820 SHED a
yt`` The Comnionwealth of Massachusetts
rQJ.V Quaid of Building Regulations and Standards CITYSALkLE�I
OF
,j Massachusetts State Building Code, 730 C vIR
Revised Mar 201/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dtivell'
This Section ForO icial Use Only
Building Permit Number: ate Ap lie fi,
lul iseb Z
dding Official(Print Name) Date
SECTION 1:N4 OOIATON
III ert Jdr??ss: 1. As ssors Map& Parcel Numbers
L la Is this an accepted street?yes no N4 Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
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: LS Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesE3
�
SECTION 2:; PROPERTYOWNERSHM'
2.1 Oww)Re��oord: MA 019 •�0
�bl'1y1 �CP.Im�4 �� e.Y✓t t
Name(Print) (�!+ City,State,ZIP
g79y1-L- 5-g6q
No.and Street Telephone Email Addres
SECTION 3: DESCRIPTION OF PROPOSED WOR.W(check all that apply) .
New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) Q Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=:
,c� /Ux l -1/
rX" SECTION 4: ESTILLaTED CONSTRUCTION COSTS
Estimated Costs:
[rem Official Use Only. .
Labor and Materials
1. Building $ I. Building Permit Fee:S Indicate how fee is determined:
2. F.lectrieal
Cl Standard.City/Town Application Fee
5
❑"rota!Project Cost)(Item 6)s multiplier x
3. Plumbing i 2_ other lees: S
I. ,\lechaoic.d (1I IAQ S List:
i. ,Mechanical (Piro S -
SnP iresion)__— .--- rotal :111 Fces:.S_
Check No. _ Check Amunt: _ l';ish \inonut
n fatal Project ('uit S ,300 r0.00 I _ n - —.—
0 1'u if) Pu Clll 011htandin"' U tl incc Uu
S �
SECTION 5: CONSTRUCTION SERVICE'S
5.1 Construction Supervisor License(CSL)
License Number E.epiratimt Date
Name of CSL Ifulder List CSL Type(see below)
Type Description
No. and Street
U Unrestricted Duildin�s u to 35,000 Cu. R.
R Restricted 1&2 FamilyDwellin
City/f otvn,State,zip ��I Masonr
RC Roaring Covering
WS Window and Sidin I
SF Solid Fucl Burning Appliances
t Insulation
1'ele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or I IIC Registrant Nmne
No. and Street Email address
City/To n,State 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 AUTHOR IZATIONTO 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: OWNERt 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 Authorized Agent's Name(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
(not registered in the floutc Improvement Contractor(HIC) Program), will not have access to the arbitration
ro gratn or guaranty fund under M.G.L. c. 142A. other important information on the HIC Program can be round at
i�ww.mas:. uv;or Information on the Construction Supervisor License can be found at ttww.mas, uyv'JL
a
2 When substantial work is planned,provide the information below:
lbrtl fluor area(sq. it.) (including garage, finished hasemenUattics,decks or porch)
in7i; living area('sy. tl.) ___ _ Ilabirtblc room count
Nlnnberuf tircpl.Ices_ —_-------_--- `umbarufbedrnnms --_--
Vumber of badtrl nns Number of ImIt`mths
I'cpc of heating sy;tcut Number of dxk;/ porches -- _--_--
I*',peufcanling ;yucut fincla;cd _ p _
CIt
f"l II F„0t I MAY hL Iil);hhll I t1II ..(.-[.II I ntlsl (") C