5 CLEVELAND ROAD - BUILDING PERMIT APP (� The Commonwealth of Massachusetts
�^ \ Board of Building Regulations and Standards TOS
�1J )
et Massachusetts State Building Code, 780 CMR, T°edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Famih'Dwelling
This Section For Official Use Only
�\ Building Permit N bee I Date Applied: 5- 1 ` Q
Signature: �—
OF
Buddin Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
ropert Ades : / Ie-L ND F9 1.2 Assessors Map& Parcel Numbers
I.l 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.(j.L C.40,554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system 13Public❑ Private❑ Check it es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record•
Name Print) Address for Service:
,
9�S7- 9zz
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
E
Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alleration(s) Addition ❑
olition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
—72
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMclal Use Only
Item Labor and Materials
1. Building SSD O 1. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical f ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: E (�\
4. Mechanical (HVAC) S List: y
5. .Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: 5 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) S
y.�
�h ' 'e L License N-umber Expiration Date
rte—
Ngme ul CSL- HgWrr List CSL Type(see below)
3 5ivr�s�7zidc
Address EDResidential
Descn uon
Unrest (u to 15,000 Cu. FlJ
ted I&2 Famd Dwellin
Signature
mial Roofin CoverinTelephone ntial Window anddmial Solid Fuel Bumin A liance Installationial Demolition
5.2 Registered Home Improvement Contractor(HIC)
,-=1/-LiOPE effi 7�GGT/i1 /-�r9 SCJ
HIC Co pan Name or HIC Registrant Name Registration Number
Address
Exf tration Date
Signature 0- 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 .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize Ur% `� to act on my behalf,in all matters
relative to work authorized by this building permit a 'lica ton.
-s- i - o S
Si nature of Owner Date
SECTION 7b:OWNEWOR 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:
1. 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. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I I O.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"