10 BEDFORD ST - BPA-15-1041 NEW DECK �} The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards RE( �.
g "I SPEC i IC,Elf R vrsed�S 2011
111 d( : - SALEM
Massachusetts State Building Code, 730 CMR
Building Permit Application To Construct, Repair, Renovate O{Dp�Solliish a
One-or Tivo-Family Drvellirrg [ I
This Section For Officiel,Use Only
Building Permit Number: Date Applied:
Building Olticial(Print Name) Signature V- - Date
SECTION 1:SITE INFORtNIATION`
1.1 Property Addresr 1.2 Assessors Map dl:Parcel Numbers
lb
I.1 a Is this an accepted street?yes_ no Map Number Parcel Number.
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(Il)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewnge Disposal System:
Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Public( Private 13 Zone:
If yesCl
SECTION 2: PROPERTY OWNERSHIP!:
2.1 Ownerl of Record: �_,��t,,,
l;
V _%J4 oLveA @-tU1 Glus'rtr `D d0 �j ,, 1i11i
thme(Print) City,State,ZIP /t
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED'WORK'(check all that apply)
New Construction Cl Existing Building O Owner-Occupied ❑ Repairs(s) ❑ Altention(s) ❑ Addition..f
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Desrlrjpt�on of Proposed Work-: U"`°('e % $
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ a5�Q I• Building Permit Fee:$ Indicate how Fee is determined:
Cl Standard CityRbwn Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier sr�
3. Plumbing $ 2`f.ether Fees: .$
4.Nlech;micel (HVAC) S List:
5. Nlechanie it (Fire . S Total All fees:S
Su ressiun)
Check No._Check Amount: Cash Amount:_
G.
rut.
Project Cult S �I Soo ❑Paid in Full ❑Outstanding Balance Due:
1 rJ-- 1-r.sem
SECTION 5: CONSTRUCTION SERVICES
5.1 ConstructioS(u� eisorLicese(CSL) V �1
VCif —`
License NumberExpiration Date
Name of CSL[[older
List CSL'fype(see below)
No. ;utd 'acct �� J Type - - - Description
S ,(�� 6l fl 1 U Unrestricted OuilJin a to 35,000 cu. It.
(v� b'V / R Restricted I&2 F:unil Dwellin
City/Town,State,"LIP ht Masonry
RC Renting Covering
WS Windowand Sidin
SF Solid Fuel Burning Appliances
1 IInsulation
Telephone Email address I D Demolition
5.2 Registered Home Improvement Contractor(HIC)
(� f Vlectrbm HIC Registration Number Expiration Date
I I IC Conp;unIIlegis Wn��nt�Zj
No. and Street It
���� Email address
Cit frown State ZIP Tel eithone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.15L$ 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 Isbuance of the building permit.
Signed Affidavit Attached? Yes ..........E3 No...........0
SECTION 7a:OWNER AUTHORIZATION.TO BE.COMPLETED WHEN• r;: '
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
I, as Owner of the subject property,hereby authorize RC�f Dtct 0,A
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Nance(Electronic Signature) Dale
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.
Print Owner's or Authorized Agent's Nance(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 net 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
x�w.v.mass.eov'oca Information on the Construction Supervisor License can be round at www.mas.uo+:'dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) .(including garage, finished basementlattics,decks or porch)
Gross living area(sq. R.) Habitable room coon
Number of fireplacesNumber of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type ofcoolingsystem Enclosed Open
3. "Total Project Square Footage'may be substituted for"'rotas Project Cost"
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