8 CLEVELAND RD - BUILDING PERMIT APP 1 n � The Commonwealth of Massachusetts
v Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 71a edition Building
Building Permit Application To Construct, Repair, Renovate Or Demolish a l
One- or At -Furntl Duelling
This Section Fo tcial Use Only
Building Permit Num Date pplied:
Signature:
Building Commissioner/I pector of Bu ing Date
SECTION 1: SITE INFORMATION
I Property Address: 1.2 Assessors Map& Parcel Numbers
4C cl2nfil Ad
1.1 a 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 n) Frontage(n)
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.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al O On site dis sal system ❑
Public❑ Private❑ Check if es❑ P po y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofRecord: � G/�`�/�� n I
yawar�l 0 j4tir A G(
Name(Print) Address for Service:
(97T) Zia
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
rTnptio7,,ofPr7posed
Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Accessory Bldg. ❑ Number of Units_ Other Specify: /7
Proposed Work': rG w,a/ir t° r' i�u ✓'n � 'n4 if i t9S fa ��
l u � S�Ir tors{r'n4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building E 10 zZ.S� 1. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical E ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing E 2. Other Fees: S
4. Mechanical (HVAC) E List:
S. .Mechanical (Fire E
Total All Fees: E
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: E �OJ 2? ❑ paid in F AI 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CS �sr V17 ZO11
'' 3License Number Expuauon Date
6 vtc Tolm ion
N.4mc of CSL- Helder
• L 11 NolliS/✓N 0- "i'ler./tru if/fR oLoSj List CS
Type Iscc below)
Address
z�Q // T y Dwelling
Lion
�_ U Unrestricted u to 35,000 Cu. Ft.)
6 R Restricted I&2 Family
Signatur M Masonry Only
(7-71/121/v'7027 RC Residential Roofin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Eluming Appliance Installation
D Residential Demolition
5.2�Re�istered Home Improvement Contractor(HIC) �ly
COn�'Y'4cil MO tnG. _ 7D
HIC Company Name or I Registrant Name Registration Number
L,Ma, VC , foul oL3O Z//Z/Z b//
Address
5pe (vy 2f Expiration Date
signaD6 Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 7n: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.
Si nature of Owner Date
T^ SECT/ION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
—
1 ,/O54u.l TOr/r7SO4 ,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.
�bS�yC� �OjIYJSO�7
Print Name
Signature of O er or Authorized Agafft Dale LO
(Signed under the pains and penalties of ju
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�f 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 IO.R6 and 1 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 he substituted for"Total Project Cost"