0003 CLIFTON AVENUE - BUILDING JACKET The Commonwealth of Massachusetts Town of
s, Board of Building Regulations and Standards
4110111111111
—Massachusetts State Building Code, 780 CMR, T"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Finaill Dwelling
This Section For Official Use Only
Building Permit Nu Kt r, Date Applied:
3 /�9
Signature: "✓ -T
Building Commissioner/Inspector of Buildings Date
SECTION l:SITE INFORMATION
1.1Propert ddress: 1.2 Assessors Map& Parcel Numbers
cf�� � s� Crab 1��
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 R) Frontage(ft)
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.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 O�}er'o /r,l1b�
Reco d: q / -�' Q
/�J�r t l �l /O
Name nnt) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) O Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other 62�Specify: ate �:r r"
Brief Description of Proposed Work=:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S 1. Building Permit Fee: E 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: 5
Su ression
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S/��a��-ad 0 Paid in Full 0 Outstanding Balance Due:
n
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) �n
Tnzr ltP License Number Expiration Date
p
fCSL H Wer
�iqcrr itList CSL Type(see below) U
Descn tion
Unrestricted u to 35,000 Cu.FlJ
R Restricted 1&2 Famil Dwellin M Masonry Only
RC Residential Routing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Bumin A liance Installation
D I Residential Demolition
5.2 RrhteredcomeIm `
prove entCgntractor(HIC)
An�ct rC14YA
HIC Company Namer HIC Registr Name n� Registration Number
Ea t 1 & Urr v
Address _
-�LL•oG2 Expiration Date
Signa re 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
I. 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
S C ION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1. ,as Owner or Authorized Agent hereby declare
that t e statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. .
J"A'X -1-a-;.24 114
Print Name
4 ' 1 , 69
Signature of Owner or Authorized Agent Date
Si ned 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 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 10.116 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 Cosi
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