15 CLOVERDALE AVE - BUILDING PERMIT APP (003) . t
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The Commonwealth of Massachusetts s i$E,Nl In
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Board of Building Regulations and Standards SALEbI
Massachusetts State Building Code, 780 CMR 101b SEP 13e,kA10 r 2011
O Building Permit Application To Construct, Repair, Renovate Or Demolish
_ One-or Tivo-Family Dwelling
This Section For-Official Use Only
Building Permit Number. Dateplieds
-Building 011lcud(Punt Name). Signature - Dote
SECTION 1:SITE INFORMATION
1.1 Pr perty Address: 1.2 Assessors blap di Parcel Numbers
Lin Is this an accepted street?yes no Islap Number Parcel Number
[1.6
'Zoning Information: 1.4 Property Dimensions:
ing District Proposed Use Lot Arca(sq R) - Frontage(It)
Building Setbacks(R)
. Front Yard ,Side Yards - Rear Yard
Required Provided Required _ Provided. Required Provided
Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Munici al O On site dis sal s stemic l7 Private O — Check if esO p pa Y
SECTIONZ: PROPERTYOW_ NERSRIP!
2.1 Ownern of Record:
PATRIGA LL09AS Cal c�1 >nA• n)470
tlme(Print) - City.State,ZIP
15r CLOVU AIL A✓F 9787'14-„200
No.and Street Telephone Email Addrrss
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction O Existing Building Owner-Occupied Repairs(s) O Alterotion(s) 0 1 Addition O
Demolition ❑ AccessoryBldg.O NuntberofUnits_ _ I Other Speciy: WF_ATHFRIZA7MA1
Brief Description of Proposed Work-:
,1/JSUG9Te R77-jG EKTERtnk a/AiCS uliTN BLt)U)N OA-11O 61
SECTION-1:EST161ATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 00 I. Building Permit Fee:S Indicate how fee is determined:
0 Standard City/Town Application Fee
2. Electrical $ p Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2?Qther Fees: S
4. `Icchanical (HVAC) S List:
5.�\fechanieai (Fire S Total All Fees:S
Su ression)
Check No. Check Amount: Cash Amot nt:
G. Total Project Cost: S 360;7;a70 Paid in Full ❑Outstanding Balance Due:
TO _ C..
MA \4_'�—_Y_) o1 'Zz
1 SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) rg- 1667Se '1
BRAD ��11) F License Number Expiration Date
N:une of CSL Holder List CSL Type(see below) (�
15' IMA1AAI Rn Type, Description
No.and Street -
U UnrestricteLguildin"'tip to 35,000 cu. tl.
lEL1J Ol8 D R Restricted M F:unil Dwell 17;
Cityfrown,State,Z P N Masonry
RC Roolin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Tele honeD Demolition
Email address
5.2 Registered Home Improvement Contractor(HIC) �16-5W
S7/CCA (AA)7R6C'f1A1(,^ Q-) - - HIC Registration Number Expiration Date
MIC Company Name or HIC Registrant Name
371 UMS91N(T6N SY"
No.mid Street Email address
9 " k7- !-59,2-6919
Ci /Town State,ZIP - Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O,I:.c.ISL§2SC(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 Isivance of the building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7a:.OWNER AUTNORI2ATION TO BE.COMPLETED WHEN, "
OWNER'S AGENT OR CONTRACTOR•APPLIES FOR BUILDING PERIWIT
I,as Owner of the subject property,hereby authorize STI CCA MAITRACYiAIG CD
ink qgt on my behalf,1 II matters relative to work authorized by this building permit application.
R97-AU-1A LIWA&
Print Owner's Ndme JElectronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in thi application is true and accurate to the best of my knowledge and understanding.
f)A1dFF 8�s/G
in Oiwie s or,Authorized Agent's Name(Electronic Signature) Date
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 ngl have access to the arbitration
--- - —
program or guaranty fund under M.G.L.c. I d2A.Other Imtant porinformation o"ri iha HIC Program can noun
+eww mass t:ov;'oca Information on the Construction Supervisor License can be round at www 11g;j ro+%'dns
2. When substantial work is planned,provide the information below:
'rota) fluor area(sq. R.) N (including garage, finished basement(attics,decks or porch)
Gross living area(sq. fl.) 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 ofcoolingSystem Enclosed- Open
3. ,rotal Project Square Footage"may be substituted tar"Total Project Cost"