1 CLAREMONT RD - BUILDING PERMIT APP (003) 413 The Cum monwcalth o(Massachusctts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'a edition
wlding Permit Application To CunstrucL Repair, Renovate Or Demo:h *
Odoom
ne- is eco-Fumih Dwelling
This Section For Official Use Only
ermit Num r: Date Applied:
-� 0
Bwlding Commissioner/I spector of Buildings Date
SECTION 1: SITE INFORMATION
rDistrict
PrortAddress: .. / 1.2 Assessors Map dt Parcel Numbers
endo-t �1
r Ma Number Parcel Number
accepted street'. yes_ no P
nformation: 1.4 Property Dimensions:
Proposed Use Lot Area(sq 11) Frontage(n)
LS BuildingSetbacks(ft)
Front Yard Side Yards Rear Yard
RequiredFI
Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c. 40.I54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system E3
Check if vesO
SECTION 2: PROPERTY OWNERSHIP'7��werd: / r ��Address for Service:
791 346 Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition 01 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': .S^�v,�r eKlslMa GWyw ��..ri .1/ '1"y -a
ihb��l /k,� Cl�obw�(y
SECTION 4: ESTIMATED-CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building fI. Building Permit Fee: f Indicate how fee is determined:
2. Electrical ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing 2. Other Fees: f
4. Mechanical (HVAC) List:
S Mechanical (Fire
-5 cessionTotal All Fees: S
No. _Check Amount: Cash Amount:_
h. Total Project Cost: ❑ Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.I Licensed Construction Supervisor(CSL) 0 4J 73°f
*6441 4��t�d,klL License NumRr Eaprnuon Date
Nyor of CSL- HjIte�r
' JOU �}./I fi'�lN,./
List CSL Type last beluwl
---� T� O----------
Address
stri tion
Address U Unrestricted u to)5,000 Cu. Ft.)
7 R Restricted Iek2 Famd Dwelhn
Signature N Masonry Only
,7;7 ?-7 (007 RCRcsidennal Rooftn Covering
Telephone WS
Rrsidennal Window and Siding
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
S. Re�stered Home Improvement Contactor(HIC) 15 !'t
e�f �i'2x� �io0�3 J �i
HIC Company Namg�F(IC Jj�istrark f�arpe� Registration Number
2a� 3✓rr� d l/ HS/tl 9�j�G�
Add S.>u 9'Y( ISS S S
Eapuatton Date
Si Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.; 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...........O
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
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, 4. , 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
beh�lfs
int Name
i a urc tier 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 ad 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 I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. FL) (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 haifbaths
Tvpe of heating system Number of decks/porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage" may he+uhstituted for 'Total Project Cost"