10 BRADFORD ST - BUILDING JACKET s Y
Thr Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Revised Jumiury
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 20011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature: ()
Building Commissioned Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property/ddre 1,2 Assessors Map& Parcel Numbers
�! cr 1--) € o it 0
1.1 a Is this an accepted street?yes_ V no Map Number Parcel Number
1.3 Zoning Information- / J� 1.4 Property Dimensions:
g—a
Luningoning D Proposed Use v Lot Area(sq A) Frontage(11)
1.5 Building Setbacks(R)
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 XesD
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record: �J
�O nii� J✓ '/�i`P ret?i �V 8"� Ot
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': w.p g
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
Labor and Materials y
1. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2.Electrical S 11Standard CityRbwn Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S g Q l7,p ❑Paid in Full O Outstanding Balance Due:
�61
SECTION S: CONSTRUCTION SERVICES s
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I lolder Lisa CSL Type(see below)
F) Descrition
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1.42 Family Dwelling
Signature M Monl
RC Residential RoolinitCovering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or IIIC Registrant Name Registration Number
-------------
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.3 2SC(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 AUTHORIZATION TO 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 b ' g permit application.
Signature of Owner Date
SECTION 71s:OWNEW OR AUTHORIZED AGENT DECLARATION
1 �pOr�ir A 7fvll elyc" as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. L� C
print Name 6
Signature of Owner or Authorized Agent Date -�
(Signed under the pains and penalties of 'u -
NOTES:
1. 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 Mal have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"maybe substituted for"Total Project Cost"
/\ The Commonwealth of Massachusclts
�\ Board of Building Regulations and Standards TOE
.Massachusetts State Building Code, 780 CMR, 7"'edition Budding Dept
Building Permit Application To Construct. Repair, Renov t Or Demolish a
One.or Tiio-Finn Due ling
This Section orOfirjctA U On
Building Permit Nu m c Date 1 11 i Jd
Signature:
Building 0 A loale
SECTION 1:SITE I RMATION
I.I Property/V '9/-` /��� Jl-«e7L 1. Aueao�MapdtParcelNumben
1.1 a Is this an accepted street'?streeat'?yes no Map Number Parcel Number
IJ Zring information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq II) Frontage(It)
1.5 Building Setbacks(it)
Front Yard I Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.l.c.a0,1sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone' _ Outside Flood Zone? Munici al O On site disposal system O
Public O Private O Cheek if sO P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:,'d
Name(Print) !j , Address for Service: )'"o
Signal ve Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O .Existing Building O Owner-Occupied O Repairs(s) O 1 Alteration(s) O Addition Cl
Demolition O Accessory Bldg.❑ Number of Units_ Other O Specify:
Brief Description of Proposed Work':
04
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)x mulllplier x
J Plumbing f 2. Other Fees-. S
a. Mechanical (HVAC) S List:
S Mechanical (Fire S Total All Fees. S
Su ression
Check No. _Check Amount: Cash Amount_
6 Total Project Cost I S ; p 0 0 Paid in Full 0 Outstanding Balance Due:
s�
SECTIONS: CONSTRUCTION SERV7CES —
S.I Licensed Construction Supervisor(CSL)
Liccroe Number Espirmion Date
Name of CSL- Ifglder Lm CSL Type Ixv beluwl
Type Description
AJd ess
U I Unrestr eel(up to 33,000 Cu Ft.
R Res ctcd l&2 Family Drellin
Signature M %fawnry Only
RC Restdenual Roofing Covenn
Telephone WS Re . 'm at Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Repstrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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.......... O No........... W
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, POn a� c� S7�r`i'rr as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative
to w irk authorized by this uildin rmit appl' ion.
7 -,1V-2;1�
Signature of Owner Data
SECTION Its:OWNEW OR AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Sw ned under the pains and penalties of perjury) -
NOTES:
1. 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 yA have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110 IRS.respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenVattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of area
Number of halfbaths
Type of hearing system Number of decks/porches
7y pe of cooling system Enclosed Open
1 "Total Protect Square Footage" may he +uh+tituted for-'Total Proicct Cost"