4 CLARK AVE - BUILDING PERMIT APP (002) f The Commonwealth of Massachusetts
U '1 Board of Building Regulations and Standards CITY
/I t Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM
'e. RrvisrdJ ntrury
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2()()8
A One-or Two-Family Dwelling
This Section For Offtclal Use Only
Building Permit Numbe : D e Applied:
Signature: J. y/5/��
Building Commissioner/Inspecor o`Bui in Date
---- _.-_e�Tc_rNFORMATION
kssessors Map At Parcel Numbers
Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
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?Check if yesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 C` {j✓t'
Name ice:
-7
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': f� O 0,1- o C
_ AZ6 f A_) 24262Ij/rJG
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofticlal U Only
Labor and Materials Use n
y
I. Building $ 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical $ ❑Standard Cityfrown Application Fee
(3Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S / \
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
6.Total Project Cost: S r�
p0 Check No. Check Amount: Cash Amount:
r 7 t�d� 0 Paid in Full ❑Outstanding Balance Due:
r . I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) OcsD 3 ej 3
L191)3TI AJ if LC2 I.icense Number Expiration Date
Name of CSL-I[older r List CSL Type(see below)�_
3 N a94/f/iA/xxS G l2 f.PC Description
Address U Unrestricted(up to 35,000 Cu.Ft.
a r R Restricted 1&2 Family Dwelling
Signat M Mason Only
RC Residential Roofing Covering
1'elephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
' LG JD ep5
j. LO5 _
Registration Number
FIIC Company Name or IIIC Kept I Name I
Address / C ORI) Expiration Date
Signature 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 .......'...❑ No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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 ,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
behalf. _ U —t D
JYIE a
Print Name / O
Signature of O ner 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 no.1 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 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 Cost"