8 BEDFORD ST - BPA-14-560 PELLET STOVE IL 21
Fhe Commonwealth of Massachusetts
W
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Afar 2011
One-or Two-Family Dwelling
This Building permit Numb r: Section For Off cial Use Only
e Ap
Bolding Ofti iul(Print ;
gnature, D e
SECTION 1:SITE INFORMATION
1.1 Pxthisa d accepted
5`j �1 1.2 Assessors binp Sr parcel Numbers
L I a Is this an accepted street?yes no Map Number Parcel Number
to "Coning information: 1.4 Property Dimensions:
Zoning District Proposed Us,—
Lot Area(sy It) Frontage(It)
I.$ Building Setbacks(ft)
uired
Re
Front Yard Side Yards
Rear Yard
q Provided Required Provided
Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Fiood Zone Information:
Zone: L8 Sewage Disposal System-
"Public❑ Private❑ _ Outside Flood Zone?
Check if esO Municipal❑ On site disposal system ❑
2.1 vn r'o
SECTION 2: PROPERTY OWNERSHIP.`
f R
r 1)rd:e���,,,�
Nyane(1 nnt)
City,State,ZIP
No.m:J Street
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK?(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units
Brief Description of Proposed Work': Other ❑ Specify:
o ✓P
e i
SECTION 4: ESTINL�TED CONSTRUCTION COSTS
tell] Estimated Costs:
Labor and Materials) Official Use Only
I. Building $ I. Building permit Fee:$ Indicate how Fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
-
3. Plumbing $ ❑Total Project Costa(item 6)x multiplier x
2. Other Fees: $
4. Mechanical (HVAC) $ List-
it, (Fire
Suppression) $ Total r\II Fees:S
l�S 6. Total Project Cost: .S �i�d Check No.—Check Amount: Cash Amount:_
U 0 Paid in Full 11 Outstmtding Balance Due:
. I
SECTION 5: CONSTRUCTION SERVICES
j.l Construction Supervisor License(CSL) License Number Eturation Date
List CSL'rype(see below)
Name of CSL Holder (
type Description
No.and Street U Unrestricted Buildin S u to 35,000 cu. ItJ
R Restricted 1&2 Fami1 Dwellin 1
M Mason
City(I'own,State,ZIP RC Roolin Covering
WS Window and Sidin^
SF Solid Fuel Burning Appliances
I Insulation
-nmil address U Demolition
'fete hone
5.2 Registered dome Improvement Contractor(HIC) HIC Regis r Expiration Date
IiIC Company Name or HIC Registrant Name
Email address
No.and Street —�
Telephone
Ci /Town,State,ZIP - -
SECTION 6:WORKERS' INSURANCE AFFIDA
.COMPENSATION VIT(M.G.G.c. 152.§ 25C(
Workers Compensation Insurance affidavit must be compl eted 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 ..........
13 SECTION 7a:OWNER AUTHORIZATION IE BFOR BUILDING
WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
tg act on my behalf,in all matters relative to work authorized by this building permit application.
Date
Print Owner's N:une(Electronic Signature)
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my nam ow,I hereby,attest under the pains and penalties of perjury that all of the information
tt contained in this plic to rue and accurate to the best of my knowledge and understanding.
Date
Print Own• 'or uthorized Agent's Nunto(Electronic Signature)
NOTES:
I. An Owner who obtains a bre
uilding permit to do his/her own work,or an ovi willne hter xhavehacass to res an thearbitration
(not registered in the Home Improvement Contractor(HIC) Program),
rtant
program
nmor guaranty fund don on the Construction OhSuperver osor License can be foundormation On the latCvProg,t_ 't s_Yv'�`hts and it
2. When substantial work is planned,provide the information Bludinelo w�ge, finished basement/attics,decks or porch)
Total door area(sq. ttJ Habitable room count
Gross living area(sq. RJ Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches
Type of heating system -- Enclosed_—Open
Type of cooling System
1. "'total Project Square Footage"may be substituted for"'rota) Project Cost"