62 BRIDGE ST - BUILDING INSPECTION y ` D
The Commonwealth of Massachusetts CAL'° RVlC
Board of Building Regulations and Standards 1�14 Cq EM S
Massachusetts State Building Code, 780 CMR keel
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: Date App ' di
Building Olticial(Print Name). Signature D
ate
SECTION 1:SITE INFORMATION
1.1 Property 62 Assessors biap d's Parcel Numbers
I.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arcs(sy tl) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.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 yesE3
SECTION2: PROPERTY OWNERSHIP!
2.1 Owner of cord:
�me(Print) City,State,
No. and Street el ph lie Email Address
SECTION 3: D SCRIPTION OF PROPOSED WORW(check all that apply)
New Construe ion O Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterntion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor mtd blateri
1. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical 5 ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S P Qther Fees: .S
t. Mechanical (HVAC) S List:
5. Mechanical (Fire 5 Total All Fees: S
Su ression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S � ❑ Paid in Full ❑Outstanding Balance Due:
St'wr -ro ,71A oj z%
SECTION 5: CONSTRUCTION SERVICES
5.1 Cmistruction,Supervisor Lichvtse(CSL)
OM / �0.C5 License Number Expiruli ate
Name of CSL Holder l List CSLType(see below) L
No. ;md Street
Type' j Description
\A U Unrestricted(Buildings u to 35,000 cu. It.)
A �1 R Restricted 1&2 F:artily Dwelling
Cityfrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
i
fJ I I Insulation
Tele lon Email address D Demolition
5.2 Registered Home Improvers ent Contractor(HIC)
HIC egistration Number E.4pirilfion Date
HIC Cunt : a c fl 11 • t Nalmee
No. and StreetEmail address
A�t A'yIVA,f� 1 !i
City/Town,StateZIP 'foie hone
SECTION 6:WORKERS,COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 25C(6)),
Workers Compensation Insurance affidavit must be comp) d submitted with this application. Failure to provide
this affidavit will result in the denial of the Wilts ce pfffe building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO HE COMPLETED WHEN "
OWNERIS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize �V
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) DateI,
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
6y entering my n e be w, I hereb attest under the pains and penalties of perjury that all of the information
contained in this pplic ion ' true d ac ate to the best of my knowledge and understanding.
f
Print Owners or At hurt d rlgent' N;unc(Electronic Signature) Da
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'oca Information on the Construction Supervisor License can be found at www.m:us.��ov:'Jos
2. When substantial work is pl.•mned, provide the information below:
'total floor 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 Footngc"may be substituted 1'or"'road Project Cost"