18 BRADLEY RD - BUILDING PERMIT APP 4w
'J I he Commonwealth of Massachusetts
-� Board of Building Regulations and Standards CITY
d7 F\ Massachusetts State BuildingCode, 780 CMR, 7ib edition OF SALEM iJ � Revised Jutruurr
Building Permit Application To Construct, Repair, Renovate Or Demolish a i. 1008
OPq or Tivo-Famil.v!qivel(inK
is Section F OMcial Use Only
Building Permit No er: Date Applied:
Signaturf
Boil ing Commissioner nspector oIBuildings Date
SECTION I:SITE INFORMATION
1.1 Pro er?Odd ss* r` n I 1.2 Assessors Map Rr Parcel Numbers
I.1 a Is this an accepted st t?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R)" Frontage Ill)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ P p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: /
a,eah — pase ieeA) OCOSA)4 ✓ /-3 /3esg �el
Name(Pri t Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work-: Ale-.a Ly 1 a/ clQ W 3 1 i A
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building $ 3.2 oo U I. Building Permit Fee: $ Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire $
' Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
qJ �.
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
JZ' KC l.icensc Number Expiration Date
N:unc of CSI. 1der -
sr �6\.� Z Cl/! List CSL Type(see below)
FN,pe I Description
,Wdr•
qkeU Unrestrictedu to35,000 Cu. Ft.)
't R Restricted I&2 Family Dwelling
y re M Masonry Only
r RC Residential Roofing Coverin
Telephone WS Residential Window and Siding
y/-/65 s SF Residential Solid Fuel Burning Appliance Installation
U Residential Demolition
7�;egiste orn ly(pro a/t ontractor(HIC) �� 7
IIIC C,om tt 4 `o�IC Reysiriatt N /,c — te�bistration Number
ress 'i �'11 eeLL
WV-f7y1^1(o//- Expiration Date
Signature I Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.§ 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 .......... ❑ 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 building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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
(Signed under the pains and penalties of perjury)
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 nor 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 I I0.R6 and 110.115,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 halt7baths
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"