10 BEDFORD ST - BPA-14-366 GENERAL RENOVATIONS The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
_. This Section For Official Use Only `
Building Permit Number: Date Ap ied:
fit armUX
�i!I 3n 1
Building Official(Print Name) Signature - - .Date
SECTION 1:SITE INFORMATION
1 Pr?7rtL J dres�: 1.2 Assessors Map&Parcel Numbers
r
1.1a 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 OWNERSHIPS ..
2.1wner'of ecor
,P,.n�e a 44 N� fl d79
Name(Print)T - City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) '
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑qSpecify:
Brief Description Proposed Work : ' l Of
&,V
—7T SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)-
1.
aterials 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost"(Item 6)x multiplier - x 1
3.Plumbing S 2. Other Fees: $ -
4.Mechanical (HVAC) $ .List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No._Check Amount:' Cash Amount:
6. Total Project Cost: $ DOD ❑paid in Full ❑Outstanding Balance Due:
4355
` SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Super/m sor License(CSL)
14 few / ' Al by o 5e L Expiranon Dat
Name of CSL Holder (/p -
n� n /ae / /irk List LTy a see below)-U
No.and Street , 1 �',,II � l Type Description
Sa /p� yt^ G 1 Q G U Unrestricted(Buildings u to 35,000 cu.ft.
b l , – 1 / / / R Restricted 1&2 FamilyDwelling -
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
y Q e n SF Solid Fuel Burning Appliances
IInsulation
Telephone Email address D Demolition
5.2 Re istered Home In ovement Contractor(HIC) 9 / _)
Xc' wyl/ � ,bnl – 141C Registration 2�
Number Expiration Date
HIC pa Name o HI egi r nt-Nam
N–o�Ad S`el��/ 4 L" on,4 Q er fyo lzs-7fo-3,5'1 Emai nt�s
City/I own,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insuranceaffidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan 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 Own r of the subjectproperty,hereby authorize r t?�C,
to act o behalf in all r Iters relative to work authorized by this building permit application.
Print wner's Name(Electronic 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 Authorized Agent'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. 142A.Other important information on the HIC Program can be found at
Lv w.mass.eov/oca Information on the Construction Supervisor License can be found atwww.mass.gov/dps
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"