1 CLAREMONT RD - BUILDING PERMIT APP y'
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards r
Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
e- or wo-Family Divelling AWOL
This S ction For Official Use Only
Building Permit umbe . Date Applied:
��rr
Signature: J s
Building ommissione for o(Buildings Dale
SECTION 1:SITE INFORMATION
1.1 Pr e�ty Address: II 1.2 Assessors Map& Parcel Numbers
L � l/6r61^^^nnT rot
1.1 a Is this an accepted street?yes no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ill Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required 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 13Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record: 9
A 6ef— �N WC/ I
Name(Pont) Address for Service:
Signature Telephone
SECTION 3: DESCRIP ION OF PROPOSED ORKr(chec all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work - _ 0 B ,
r k O ( [ t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 1275776
r, S 5 7 License Number Expiration Date
N.4mc u CSL- Helder
List CSL Type(see below) l/
Address EDResir'dential
Description
5 SGe� /( 4 Unrestricted u to 35,000 Cu. Ft.) /
Signature ted 1&2 Famd Dwellin
Only
ntial Roofing Covering
Telephone 7 O / / ntial Window and Siding
ntial Solid Fuel BurningAppliance Installation
l Demolition
5.2 a ist9red Home i prov menl Contractor(HIC)
/%l drew , 'a 5� J �l-7
HIC ompany ame or HIi�gC Registragt Nam Q 4 Registration Number �i
Address T_ G
L -7 O O `-2 `j J/ Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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.......... O 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
SECTIO ER' OR AUTHORIZED AGENT DECLARATION
I, ,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 ofperjury)
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 no have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS, 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 half/baths
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"