2 CLARK AVE - BUILDING PERMIT APP (003) I
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The Commonwealth of Massachusetts ,DIVE
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• I'� � Board of Building Regulations and Standards :fib"Ps.�F At' AL�d
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or DerAMS0 3 P 12: 43
Famil
One- or Two his
Dwelling
Tbis Section For Official Use Only
Building Permit Number: Date Applied:
'9 ll s v,
I Building Official(Print Name) Signature Date
IVW^I SECTION 1: SITE INFORMATION
1.1 Property Address- ���t 1.2 Assessors Map&Parcel Numbers
1.1a 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 OTl d of Rec+ord•: �
( I )IdrM LLI
Name Print J, City,Slate,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK Z(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-: PRO
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
1. Building $ 1. Building Permit Fee: $,;�Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression) Check No. Check Amount: Cash Amount:
6.Total Project Cost: Fs-a�-6(3
❑Paid in Full ❑Outstanding Balance Due:
MA&k LCD TLC U3
SECTION 5-
5.1 Cons"Ction SUperyjspi License(C$j) CONSTRUCTION SERVICES
(rrint)— N�o o c t� � IScense NUEaveer pi
List CSL Type(see below)
No.and S t Type Description
Ilia U Unrestricted(Buildin s up to 35,000 cu.ft.)
Kyt luwu,State,Zip R Restricted U,Famil Dwelling
M Maso
RC Roofin Coverin
Cell# lephon t WS Window and Siding
SF Solid Fuel Burning Appliances
onsrruction Su ervisor tree 1 InSUlation
D Demolition
' i'as[ered Home Improvement Contractor(ffiC)
(Print C pony Name or Name HIC Regi� a xp' ation Date
No.and Svee
rs Signature
Crty/Town,State,ZIP Telephone
SECTION 6:WOREERS'COMPENSATION INSURANCE AFFIDAVIT Emad address
c.152.§25C(�)
Workers Compensation Insurance affidavit must be co feted and submitted with this application. Failure to
provide this affidavit wiII result in the denial of th ance of the building permit.
Signed Affidavit Attached., Yes..........For No...........ii
❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUJH,DIIN-}G PERMIT
I,as Owner of the subject property,hereby authorize(print name) a g6r//
act on my behalf,in all matters relative to work authorized b this building to
Y i g permit application.
/Print Owner's Name / Signature
SECTION *;D:r:�_
7b:OWNER OR AUTHORIZED AGENT DECLARATION OR CSL HOLDER
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
containe lic on is true and accurate to the best of my knowledge and understanding.
r
Owner's or Authorized Agent's/CSL Holder Name '�' 'Ry//' /L�
/ ✓ 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the MC Pro www.mass-goy/oca Information on the Construction Supervisor License can be found at www.masss,o/dan e sound at
In accordance with M.G.Lc. 40 154A. A condition of this permit is that all debris resulting from this work shall be
disposed of in a licensed waste facility as defined by M.G.L.111 §150A. *Dempster on site OR removed off
site *Dempster Co.Name
Address