48 CLARK ST - BUILDING INSPECTION (5) Gl� o �> SC Z 9 on IL 5
R C IIItF I
The Commonwealth ofviassachusetts INSPECTIONAQ SERVICES
CITY OF
Board of Building Regulations and Standards ALEM
q % Massachusetts State Building Code,780 CMR 2015 JUL 10 Avj d h&2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Onl
Building Permit Number: Dat Applieds
9
BuilJing Olticial(Print Name). , Signature - '. Date
(� SECTION I:SITEINFORlV1AT(ON`
I.1���PjjQQper��}Address: 1.2 Assessors t�lnp&Parcel Numbers
^ "fro C�—�qje—
�{-J 1.1 a Is this an accepted street?yes L-� no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(it)
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 O On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION2. PROPERTY OWNERSHIP!'
2.1 Ownert of Record:
�me(Print) City,State,ZIP
,tG nl_4 51' �FZ� L�715�
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alterations) ❑. Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-:
'Wlo S'(�4Jc�^•r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item tEstimated Costs: Official Use Only
and Materials
I. Building D1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical — ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing !*Other Fees: S
:1. Mechanical (HVAC) S LisC
5. Mechanical (Fire S Total All Fees:S—
Suppressiun)
�j � Check No._Check Amount: Cash Amount•.
6. •rotal Project Cost: S /.�D ❑Paid in Full ❑Outstanding Balance Due:
SENT Pia Qs.�•s-�� -�� t�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction S upervisor License(CSL)
License Number Expiration Date
i ame of CSL Huller (,
List CSL Type(see below)
4� F0"64= 'gn, Description
No. ;md Street T s
Unrestricted(Buildings tip to 35,000 cu. tt.
4A-Qe -l4 ,(( "A- 0lg l; — R Restricted 1&2 Family Dwelling
Cityllbwn,State,ZIP wl —1-1fasonry
RC Rooting Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered` Home Improvement Contractor(HIC) / 7%S93 io
A_ l�t A1✓�[}x+5 HIC Registration Number Expiration Date
HIC Cum :my Nmne or 11IC Registrant Noma
s e s.vr- ramr
No. and Street Email address
City/Town,State,ZIP 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........... ❑
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 Andgl- W)e-�
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nmne(Electronic tgnalure) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
P nt Owner's or Authorized Agent's Name(Electronic Signature) Date
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 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
www mass env:'oca Information on the Construction Supervisor License can be found at www.m issoov/dos .
2. When substantial work is planned,provide the information below:
'total fluor area(sq. R.) 'a _.(including garage, finished basement/attics,decks or porch)
Gross living area(sq. it.) 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 ti)r"total Project Cost'