13 BRADLEY RD - BUILDING PERMIT APP �- u - i-� �
The Commonvvealth of Massachusetts RECEIVE CITY OF
[� Board of Building Regulations and StandartNSPECTIONAL S RVICM[vl
1 � � Massachusetts State Building Code, 780 CMR Revised alur 2011
Building Permit Application To Construct, Repair, Renovatej�j44ol�sba ' 4F
One-or Two-Family Dwelling
This Section For Official Us Only
(� Building Permit Number: Date Ap led
Duilding Official(Print N:une). Signature Datd
SECTION 1:SITE INFORMATION'
I.1 Property Address: ( c� EtA
ors Mnp& Parcel Numbers
�'ivcLZ cc J l r wl
L I a Is this an acce ted street?yes \V no er Parcel Number
1.3 'Lolling Information: rty Dimensions:
"Coning District Proposed Use y It) Frontage(It)
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,§SJ) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone' Municipal❑ on site disposal system (3
Check if es❑
SECTION2: PROPERTY OWNERSHIP!'
2.1 O nert of Record. . ^
17thme(Print) City,State,ZIP
13 F�t�>PI� f
Nu.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) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other W Specify:
Brief Description of Proposed Work-:
n ^ e t
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I Building S 1c' I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Tawn Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier //x
3. Plumbing Y !!sptherFees: S / C/
d.Mechanical (l-IVAC) S List:
5. Mechanical (Fire S Total All Fees.S
Suppression)
Check No. Check Amount: Cash r\mount:
6. Total Project Cost: .S IC7 (- ) ❑Paid in Full ❑Outstanding Balance Due:
- -— tL l $
OL
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Licgilie(CSL) C7 Nu (o— 1� — i >di3"1
License Number E.•cpiration Dale
Name of CSL Mulder "„+ List CSL"type(see below)
\ Type Description
No. and Street
^� e U Unrestricted(Buildings u to 35,000 cu. It.)
C-Ct L cxx`1 tM of O A (.c) R —Restricted 1&2 Family Dwelling
Cityffown,State,ZIP bf Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tcle hone l mail address`'6 ,t • ,rw D I Demolition
5.2 Re istered Home Improvement Contractor(HIC) 1-)3 8(=-:� 11-ac i5
HIC Registration Number Expiration Dade
HIC Copipany Nam"
am• H No IC Registrant ne
S o `�e,-,- -)a t
No. and cet7 4A Email address
q'\G.,,.+ VAA A 01e Id 'may ( 1"�UJ
City/Town, State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 15L§ 25.C(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 .......... 01--' 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Natue(Electronic Signature) Dale
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereb attest under the pains and penalties of perjury that all of die information
coritairted in thi ,pplication iPr !n!acc to to the best of my knowledge and understanding.
� � -ID- �
Prin •r's or Authorized AgenPs Nani• ectronic Signature) Dale
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. I42A.Other important information on the HIC Program can be found at
www mass eov'oen Information on the Construction Supervisor License can be found at www.mass.uov!Jos
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. 11.) 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 ofcooling systeni Enclosed Open
3. "Total Project Square Footage"may be iubstituted litr"Total Project Cost"