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21 CLARK AVE - BUILDING PERMIT APP (002) ���� � � � ���3� s , � � � The Commonw�lth of+Massachusetts /o,r � Board of Building Regulations and Standards CI7'Y OF (`� Massachusetts State Building Code,780 CMR SALEM �l_) Revised Mar 2017 /' Building Permit Application To ConsWct,Repair,Renovate Or Demolish a a� One-or Two-Family Dwelling , Tt�is Sedion Fo[O$�ici �se Only f � Building Pemut Number.� - Date pplied: �� � Building Official(Print Name) �' Signature�� Date �� SECTION 1: S1TE INFORMATION -_ i 11 P�ro le��q:� � �� 1.2 Assessors Map&Par 1 Nambers l.la Is this an accepted street?yes_ no MapNumber Parcel Number 1.3 Zoning Information: 1.4 Proper[y Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Requ'ved Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.4Q§54) 1.7 Flood Zone Informallon: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Munici ❑ On site dis sal stem ❑ Public❑ Private❑ Check ifyesO � pO � SECTTON 2: PROPERTY OWNERSAIP' 2.1 Owner'of Record:...- .. . � . ... . . . . .. . . . . .. sr�.r��� 4-►-��✓ �-�. �"►-fi b�5 rJ!ti9B Name(Ptint) - Ciry,State,ZIP '�� � L��h��l l�(le �- �-fr- '� ��l1&4�i No.and Sdeet Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(c6eck aR that apply) �New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) �'� Addition �❑ Demolition ❑ Accessory Bldg. ❑ Number of Units O[her ❑ Specify: Brief Description of Proposed Worl�': I3 c+i� 3(JC t�J J�J� G s r�L�(/G �(, G l� Z , kl L'-.r c ..� SECI'ION 4:ES`CIMATED CONSTRUCTION COSTS � i, Item Estimated Costs: Official Use Ouly Labor and Materials � 1.Building $ 3 7 � �r a 1. Building Permit Fee:$ �.:�' Indicate how fee is determined:-� Uu�j— �Standard City/I'own Application Fee 2.Electrical $ � ❑ToTa)Projec[Cost�.(Item 6)x multiplier �.��x 3.Plumbing $ sUOru ' 2:�Other Fees:�$- 4.Mechanical (HVAC) $ List� �� - 5.Mechanical (Fire $ Total��Al1 Fees:$.�� � Su ression � � � - � Check No. -.��.�Check Amount: ; Cash Amount: 6.Total Project Cost $ L�� �6�. ❑p�d in Full ❑Outstanding Balance Due: SECT[ON Sc CONSTRUCTIONBERVICES 51� ConstrucNon Superv/�isor License(CSL) � �'� ���I . 1J`�✓��l�41'� '�°(/lryY.� LicenseN�ber Erzpirat� Name of CSL Holder V �-C7 �fiw c� Gw ��l N�c L'gt csL ryre(�e neiow� No.and Street Type --�Description�� � r �� � �(� W�y v G, .5� U UnrestricteA Buildin u to 35,000 cu.ft. � /V "wV3��1 � � R Restrictedl&2Famil Dwellin City/I'owa,State,ZI M Maso RC Roofm Coverin WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation � Tele hone Email address D Demolition 5.2 egistered Home Improvement Contractor(HIC) � �p�S 2 ��� ,/� / B �-✓✓� �)✓�/S G��`�`�� HIC Regishation Number Expiration Date HIC Com y Name or HIC Registrant Name �e 'n�� c �G�v �� w��G�✓ Lnw�• �-S �� � C � � No. Stree /� 9 Email address � �• � /'�lrs'}� 7J f�i 07 V �"N�'/ ' G� G9 Ci /Town,Stat ,Z Tele hone SECI`iON 6:V1!ORKERS'COMPENSATION INSiJRANCE AFFIDAVIT(M.G.L.c 152.§`25C(�) = Workers Compensation�lnsurance affidavit must be completed and submitted with t}tis application. Failure to provide this affidavit will result in the denial of the Issuance of ihe building permit. Signed Affidavit Attached? Yes ..........iH No...........❑ SEGTION 7a:OWNER Ai11'HORiZATION TO BE COMPLETED'WHEN : OWNER'S AGENT OR CONTRACI'OR APPLIES FOR BUILDINGPERMIT ' I,as Owner ofthe subject property,hereby authorize � � �/ "O v���"'� lrw�P�— to act on�y behalf,in all matters relative to work authorized by ihis building percnit application. JC��__�^"y / � Z�{Z Print Owner's Name(Electronic Signature) �� SECTION 7b:OWNER"OR AUTHORIZED AGENT DECI.ARATION By entering my name below,I hereby attest under the pains and penalries of perjury[hat all of the information contained' this application is We and accurate to ihe bes[of my lmowledge and understanding. , � Go{G��z Print Owner's or Autho ' genY ame(Elechonic Signatmc) Daze _ 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)Progratn),will not have access to the azbitration program or guacanty fund under M.G.L.a 142A.Other important infortnation on the HIC Program can be found at www mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. oe v/das 2. When substantial work is planned,provide the infortnation below: Total floor area(sq.ft.) 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