50 BRIDGE ST - BUILDING INSPECTION Job#: 1�2�7 Salesperson:
Sent to owner:
Biding Dept: Mailed:
o Fax: GTIPII:
1 _ The C�ommon"calth ul%9assarhusettS By: Fee:
130m'd of 13wlding RrEI'ulalions :tnd Standards
, a3 Ivlassachusctls State 1uilding ('ode. 7S(I CNIR. 7"' cdiuon I 'SI
+, . r
Building Permit Application To Construct. Repair, Renovate Or Demolish it RcI„,J holloal
/.
One- or Tiro-Family Dn'rllin,t 211n,S
This S ct' )n For Official Use Only
Building Permit Number Date Applied, — ---
Ila
Slgitatul'e:
Building Cununissioner/ h crlor of Bui le Dale
SECTIO I SI . INFOR:NATION
1. cog•rh' :� dress 1.2 Assessors Map & Parcel Numbers
_ t ,
Map Nwnher parcel .Number
1.lit Is this an accepted street?yes_ no_ M p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy (t1 Frontage Ili 1
1.5 Building Setbacks(ft)
Front Yard _ Side Yards - Rear Yard
1 Required Provided Required Provided Required Pro%ldcd
1.6 Water Supply: (M.G.Le.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❑
SECTION 2: PROPERTY OWNERSH�gIP' �) /
2 Ow rI o R`ecurd: f r ig 5o 131-1 dray Sfre 7
Name ri 1 ✓�- Address for Service:
x 41,16 /o it 5d 7- 9 ,
S Telephone
i enatu re
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration( Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Desert tion of P t oiled Work':
112spaii de �A
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: pfflcial Use Only
Item (Labor and Materials)
1. Building $ dp 1. Building Permit Fee: $ Indicate how fee is deternuned:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing S 2. Other Fees:
4. Mechanical (HI'AC) .$ List: j -
5. Mechanical (Fire $ 'fatal All Fees: S�
Suppression)
(/ I Check No. Check :\mount. (•:uh
j b. rota) Project Cost: $ JD 7 5 ❑ Paid In Full ❑ Outstanding Balance Due:_... _:
I ,
r
SECTION 5: C'ONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ( 55110ii
73 3 56N'umber 114irano,�--
Name of(' 'L- IoWer Type)see helow) - _-Descri oonCntrstncted i u w??.(lUU Cu. Ft.iReancted L@'_ Fannl, DwrlhneSeen tire -7!� \I;uonn Unlv�a ` / a ��yResidential Rrt�dine l'o crin,Teleplute - - Residential \vinduw and Sidin_Residential Solid Fuel Burning \ tth:mrRe.ideinml Demolition5.2 ({cgis red���Ptp24- 5'ent (�t
lit Co tpa y Nang r IIC/Ci"(i"Slrai t Nat ll' Reglslration Number
f/ ? �� r,�r 42 s/a� a a�
Address 9Q 7•7�i o�a1 ���n Date
S a 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. Fadure to prueide
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
sI, & as Owner of the subject property hereby
authorize to act on my behalf. in all matters
relativ o s ork authorized by this building permit application.
,94
Si nature ol'bwnery Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, l��/ / S / U t7h a(- O r L( ,4 — -.as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing applicatAin are true and accurate, to the best of my knowledge and
behalfOhl- z
rnn (�o(Owner or Auth rized Agent Gate
nder the ains and enalties of er'u )
NOTES:
Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
registered in the.Home Improvement Contractor(HIC) Program), will not have access to the arbitration
ram orguaranty fund under M.G.L. c. 1.12A. Other important information on the HIC Program and
struction Supervisor Licensing(CSL)can be tiwnd in 780 CMR Re,ulations 110.R6 and I I0.R5, respectively.
i ' When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including garage, finished basemenUattics, decks or porch)
I
I Gross living area tSq. Ft.) Habitable rtntm count _
Number of fireplaces Number of bedrooms
Number tit h:uhruoms Number of halt/hadt.s
repe of heating system Number of decks/porches ---___---
fype of coolant s).Stern [inclosed Open --- — -
3. "Total Project Square Footage- may be substituted for"Total Project Cost-