12 CLEVELAND RD - BUILDING PERMIT APP �& 1 U 5i t—lo r
The Commonwealth of Massachusetts
Board of Building Regulatioi CITY OF
�i�/ Massachusetts State Buiidi
pw.'=ERVICES SALEM
o Revised Mar 2011
Building Permit Application To Construct, Ij�p¢irv,(�n fye Qr Wry 4sh a
OQ One-or Two-Family WW��2/A{{p H a [ —
This Section For Official Use Only
1 Building Permit Number. Date pplied:
( Buiiding Official(Print Name). Signature ( pate
SECTION 1:SITE INFORMATION'
4L 1.1 Property ddJ.ress: 1.2 Assessors Map& Parcel Number
!a ��G1r,��
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 R) Frontage(il)
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? Municipal❑ On site disposal system O
Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 �nertofRe� Y �4 / / f o`q
Dame(Print) City,State,ZIP
o.antes— I Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ / Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Oth pecify: �C> �f�C✓/ A�CJ G!
Brief DescriptiorLpf Proposed Work--
St
2!7
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ QO ❑Total Project Costs(item 6)x multiplier x
3. Plumbing S 000 ?.a Qther Fees: S
4.Ntcch:mical (FIVAC) S List:
5.i\lechanical (Fire
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:
6.'rotai Project Cost: s 060 Cl Paid in Full ❑Outstanding Balance Due:
zoV
SECTION 5: CONSTRUCTION SERVICES
1 5.1 Construction Supervisor Liccnse(CSL)
License Number Espir
m ulion Ua e
Nae ofCSL,rH—olld�eerr Q List CSL'rype(see below) U
' �'k/r1/�/ ?-- Type - Description
No.and Street
� a U UnresiricicJ Duildin s u to 35,000 cu. Il.
( Jf 9 i, � R Restricted I&2 Famil Dwellin
City/rows,State,ZIP bl Maso
RC Roolin Coverm
WS Window and Sidin
SF Solid Fuel Burning Appliances
179'M''S'��� v 1 Insulation
Tcle hone Email addre D Demolition
5.2 Registered Home I tproveme t Contractor(HIC) 22 iC�3 �lo
�4 [fit Registration Number Exptrutwn Date
1 fI1C Coil fl Registrant None
1 � G/mo
No Street / •mail addt ss
Cif crown fate ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.ISL§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 Iskuance of the building permit.
Signed Affidavit Attached? Yes ....... No...........❑
SECTION 7a:OWN ER AUTHORIZATION,TO BE COMPLETED WHEN. i
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
tq act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) 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.
'01—rffi,J1!&1J1f Az lon,
Print Owner's or Authorized r\gent's Name(Electronic Signature) ate' '� e
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 I.G.L.c. I42A.Other important information on the HIC Program can be found at
xeww.mass.Lv'oca Information on the Construction Supervisor License can be found at www.masssov'Jns
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. II.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype or heating system Number of decks/porches
'rype orcoonng system— Enclose) Open_
3. `Total Project Square Foolage"may be substituted for"Total Project Cost"