80 BRIDGE ST - BUILDING INSPECTION (2) The Commonwealth of Massachuscns Town of
Board of Building Regulations and Standards �w
Massachuseas State Budding Code. 780 CMR. 7'"edition Budding Dept
r 1 Budding Permit Application To Construct.,Repair. Renovate Or Demolish a �
One. or risu-Fum 1'Dumllmg
This Section F r Official Use Onl
Building Permit N mber' Date Applied:
XSignature:
2 0
Budding Commissions In uddmgs Date
ECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
M Number Parcel Number
I.la Is this an xc ted street?yea ` no 'p
I.-H Zoning Information: 1.4 Property Dimensions:
Zonmg District Proposed Use Lot Area Isq Iq Frontage it)
1.5 Building Setbacks 00
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Info On. 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zonu7 Municipal 0 On site disposal system 0
Public O Private 0 Check if s0
SECTION 2: PROPERTY OWNERSHIP,
2.1 ,pwoer'of Race
rd:
l to IJ M I N Address for Service:
Name(Print)
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek ad that apply)
New Construction O Esisting Building O Owner-Occupied 0 Repairs(s) O Alterstion(s) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other 0 Specify:
r7TL
Brief Description of Proposed Work': D T d—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMCIAJ Use Only
Item Labor and Materials
I. Budding f ✓)�,0 I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S 0 Total Project Cost'(Item 6)s multiplier a
J Plumbing f 2. 018er Fen: f
X, a. Mechanical IHVAC) S List:
s Mechanical Ifire S Total All Fees: f
Suppression)
Check No. _Check Amount: Cash Amount:
h Total Project Cost f 0 Paid in Full 0 Outstanding Balance Due
r
SECTION S: CONSTRUCTION SERVICES
S.I Licensed Construction Supervisor(CSL) 31011K
% d
L.cenw Number Espuation Date
Nyee/of('SL Ilglder��.tt,, 1' r i,t CSL Type(,vc hduw)
L1--513L/.�2P.5rD T. Description
Almsf
/� U Unrestricted(us to J5,000 Cu Ft
5 rut re R Restricted 1&2 Faintly Duelling
.M .Na only
Yr RC Residential Roofing Covering
W
Telephone S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
xcL:-oU —r & 1,a/ Rvjcu-mY
HIC y Name or H C R pstram Name Registration Number
65 .a1i4l� �dE �SlG�2/�
e �f .i9 7��I �Expiration Date
i Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL f ISC(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........... a
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.
Si alum of Owner Dale
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, �Sr��tP f r�rL C , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application an true and accurate. to the best of my knowledge and
behalf.
4.�L
im N
Si#da3dv o Owner or Authorized Agent Date
(Sitified under the pains and penalties of perjury)
NOTES:
I. 'n 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=have access to the arbitration
program or guaranty fund under M.G.L. c. 102A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110 RJ, respectively.
2. When substantial work is planned.provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/anics.decks or porch)
Gross living area(Sq. Ft.) Habitable room count
:Number of fireplaces Vumber of bedrooms
Number of bathrooms Number of halfbaths
Type ofheating system Number of decks/porches
Tape efcooling ayslem Enclo,ed Open
t "Total Protect S4uare footage' may he ,uh,muted for-'Total Protect Cost"