12 BRADLEY RD - BUILDING PERMIT APP y lHie Commonwealth of Massachusetts
Board of Building Regulations and Standards CI'I')'OF
Massachusetts State Building Code, 750 C'MR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Ttr u-Familr Dlrellinp
This Section For Official Use Only
Building Permit Number: Date •\pplied:
m L L�i,=z „ctr f
Building Official(Print Narne) I re Uutc
SECTION 1: SITE 1 FORMATION
1.1 Property Address: 1.2 Assessors Nlap Par umbers
Liz
1.1 a Is this an accepted street?yes t/no_ Map Nwnhcr Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District PropuscJ Use Lot Area(sal It) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Sidc Yards Rear Yard
Reyuimd Provided Required Provided !JP1
equired Provided
1.6 Water Supply:(M.G.1.c.30,§54) 1.7 Flood Zone Information: wage Disposal System:
Public❑ Private❑ Zone: _ Otitslde Flood Lone?Check iYes❑SECTION2: PROPERTY OWNE2.1 OwnerrofRecord: 76
N;mtc(Print) City.Slate•ZIP
)16,aAfe r IZc� q '7$. 7Ny-q,Nu.and Street Telephone .mail Add
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ I Number of Units_ Other g;Specity:_z�,j
Brief Description of ProposedWofk': I< ;L i— �. �} _ 2o
5- -/
>E /arw4/(r p G �/L /- , -ram 10 ,h l<//d O : .zi"i`% avt O.�e faaU
4�_/)✓� IOW r� t G ke a
�J • C/� G'�� H/iJ �JY _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
I Labor and \laterials) Official Use Only
I. Building S r- r-1ve, O o I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard Cicy/Town Application Fee
❑Total Project Cost'(Item m x
P 6)x ulti leer _
� 1, Plumhing g ' ----
Other Fees: S
� a. \lech:micallll\'A(') S List:__ _-- N
5. \lechanical (Fire �J
Su,iression) S Total :\ItFees: S_ _—__ —_------ --------
('heck No. ('heck :\moult: C a5h Amount:
t,. Total Project Cush S SDU.O D --- - ----
❑ Paid in Full 0 Outstanding Balance Due:
�C� C CiyI��GC � 7�11 '�7S 7,csc
SECTION 5: CONS'I'RUCLION SERVICES
5.1 Construction Supen-isor License(CSL)
�/e"Lf__ /7!�--------- .____ Liconso Number f cpiraliuu Umc
Name of C'.SI. I folder
List C'SI.I)fk Liee
No. and Street
� � ll I Iareslricled(Buildings tlJP to 35.000 01 Il.l
R Restricted IR2 I'mill Y Dwellin
C a%ifo_lsn.St,,{c,ZIP _----- NI 71—amillry
_ RC Rotil'ing Covering
_.-. W'S Window;md Siding
a SF Solid Fuel Ilurning Applianecs
I I Insulation
I'de hone I'mail address D Demolition
5.2 //Registered
� Home Improvement Contractor(HIC)
L et e4F-2�424 L//, S, j on
Number Expiration]Jule
I IIC Conn Name or i IIC Its islrunt Name
f .s ore g ��i�o� n,7
7o. al et S Fmuil address
� ted
Ci /Tows(.'State,ZIP Isle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 .......--L1' No........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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 Nmne(Electronic Signature) Date
SECTION 7b:OWNERI 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 thissatio ' true an acgt{rate to th best of my, knowledge and understanding.
��
Prim Owner's ur:\udnnireJ:%gent's Name( F.ectroi Slgm arc) Dmc
NOTES:
1. An Owner whu 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 gol have access to the arbitration
program or guaranty fund under M.G.L.c. 1 i2A.Other important information on the HIC Program can be found at
%tutu n,.n..�;.1 1k.I Information on the Construction Supervisor License can be found at
2 \%'lien substantial work is planned, provide the information below•.
Total flour area(sq. II.)_ I including garage. finished basenlent'attics,decks or porch)
Gross living area(sq. il.) --_ . ----__--- habitable room count
Number of fireplaces._-. . .— _-- - --- Number of bedrooms
Number of bathrooms .-- _ Number ufllalf haths .. i
1%pe of heating s5 stem Number of decks, porches
I 1 pC UI eJ011llg i\Sfelll . . _ - _ _ I'llclowd _. __ __ Oliell
1, "fond Project Square Footage-may he substituted Ibr-1'olal Project Cost'