5 CEDARCREST RD - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts RECEIVE
Board of Building Regulations and StandaANSPECTIONAL ERVICIE(Si
Massachusetts State Building Code,780 CMR MUNICIPALITY
�f�. E
Building Permit Application To Construct,Repair, Renovate�}I�e�liJhJ Rdh+is ar 2011
1� One-or Two-Family Dwelling
UUIw This Section For Official Use Only
tU ` Building Permit Number: Date pplied:
S
IJn/ Building Official(Print Name) Signature Date
SECTION l: SITE INFORMATION
1.1 ProRRer[y Address: 1.2 Assessors Map&Parcel Numbers
-- l.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.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'of Record: C 0\00
C`fy2,�5r /u(k�0(x-e_ A
Name(Print) City,State,ZIP
S C_exckf(� e' y QL.
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check I that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': _0 G'n� I`C-2o Orn-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ I 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ [I Standard City/Town Application Fee
❑Total Project Cost?(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (FfVAC) $ List: Jam/ rY
5.Mechanical (Fire $ Total All Fees: $
Su ression
I� PP to n Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ t ❑Paid in Full ❑Outstanding Balance Due:
M A k -M m PNzV__ r"0i—
SEcTION 5: CONSTRUCT, ON SERVICES
5.1 Construction Supervisor License(CSL) CS- oS`i Ui { �k—1
`1 l j
A" ,�Z'�Y\' _ � License KumUe? Expiration Date i
Name of Cbl_NoJder �
! List CSL TN13e(see below, IU
No.and Street — T), e Description
U Umestricled(Buildings up to 35 000 cu.Ill
R Restr red 1&2 Family Dwelling
Cit);/Town.State,ZIf M Masonry
RC Roofinp Covering —�
WS Window and Sidin
r c� SF Solid Fuel Buming Appliances
n._ t
Insulation
Tele hone Email address D Demo]itimi
15.2 Registered Home Improvement Contractor(BIC)
HIC Registration Number Expiration Date
A1C Com any Name or MC Registrant Name
as�� ��.
No.and Street C �j p
��• ��0� JOO �� 9G'u) S� Email address
.Ci /Town;State, IP Telephone
SE4MON.45.WORKERS'4CC3WENSAnoN-INSURANCE AFFd33A1 iT(I11rG,1 c 35Z§ 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 Issuan of the building permit.
Signed Affidavit Attached? Yes .......... No...........13
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETER SrV#IEN
OWNER'S AGI NT OR CONTRACTOR APPLIES V.0R 8l 1LIDING,3'ERNHT,
I,as Owner ofthe subject property,hereby authorize__ALO C\� M(���•trt 1
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) _ Date
SECTION 7ti:•OWNER'flR AO TFiQRIZED AGEN I RECLARA3ION
By entering na to el w,I hereby attest under the pains and penalties of perjury that all of the information
contained in -s pl at n is true and accurate to the best of my knowledge and understanding.
Print Owner's or A ze Agent's Name(Electronic Signature) Date
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 can be found at
- w" .mass.Hoy/oca Information on the Construction Supervisor License can be found at w .mass.eov/dQs
2. When substantial work is planned.,provide the information below: f
Total floor 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"
icEnsc. CS457W
112ARH E MORDIM
IS]YEWEL➢.DR
N ATd'LEBORO W. 070 ..
Com+nissicr,c 09/18/2015
2J 'i n>nme�n,rzrsa/ o ^���q aexcr/war!,tt
- lfice a➢Consumer AiTairs&Bosines.Aegnlafion
OME IMPROVEMENT CONTRACTOR
RegisiratiuA:^;;96561_ Typl,.
Explrailor3 331'$32097 Supplemeni
POWER HOME REM'Ot3£LIi4G�;RCUF LLC.
MARK MORDINI 1 -
2501 SEAPORT DRIVE STE.Blib
CHESTER,PA 19013 Undersecretary
- Y� 9a BID eR�HI '
y.+-yx+ -' 8f1PJE iidw
9Del
� Ip91{Ik,C.
NAi7i.E96R0U(aH IRA,
Ui1b63525;, � '1 .
5DD 09II A14 eev9i.ISMDR _���