21 CLEVELAND RD - BUILDING PERMIT APP The Commonwealth oFMassaehusetttss EGjiT4�a
OF
Board of Building Regulations and StanEM
/ Massachusetts State Building Code, 780 CIV�ItptR��44 pppppptar 2011
Building Permit Application To Construct, Repair, RenovdfC A5
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
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( Building Ocial(PontName). Signature - Date
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U) SECTION 1:SITE INFORMATION.
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1.1 Pro Address: 1.2 Assessors blap&Parcel Numbers
1 pp
M �( C."LEULt L.AIUJ7
I.la Is this an accepted street?yes_ no Mop Number Parcel Number .
1.3 'Lotting Information: 1.4 Property Dimensions:
'Coning District Proposed Use Lot Area(sq ti) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) l.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public Private❑ Check if vesO
SECTION2: PROPERTY OWNERSHIP"
14 2.l Ownert of Record; t 4 6l`N-a
=] • Ctu 1-Ii��OEkSa1� City S IPf
'�me(Print)
3!5-AeDa1U6 RD V f_1�1.6°00
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction 0 Existing Building'k Owner Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition 0
Demolition O Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed W rk': sT2rP&xtst?W& s�Al i-ts diet`!Q 2e'mcs Or5PosL o/DE6t6
C[ / Q t'tE-
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllelal Use Only
Labor and Materials)
1. Building $ 0 I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical 5 Cl Total Project Cost'(Item 6)x multiplier x
3. plumbing $ ??Qther Fees: $
4. Mechanical (FIVAC) S List:
5.Mechanical (Fire S Total All Fees:S
Slip ression)
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: 3 /O UUQ ❑Paid in Full O Outstanding Balance Due:
5Eq'-�V c�NT
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SECTION 5: CONSTRUCTION SERVICES
5.14nstruction Supervisor License(CSL)th/2/� LrceneNumer E.xpratio Date
Name ofCSL Holler
List CSL'fype(see below)
43 /°O4ft !
Type Description .
No.;ad Street
& -
A,,1,, �7 U Unrestricted(Buildingsup to 35,000 cu. It.
r�l"lUrlV �1��06 R Restricted 1&2 Familv Dwelling
Cityfrovm,Sraat IP M Imasonry
Roolin Cc Grin
S - Window and Siding
F Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D I Demolition
52Registered Home
,Y"Improvement Contractor(HIC) )61
r) �
/4N (�/t I/ ! 17 xk- 5 HIC Registralio Number E.pi ton Dale
f IIC Co tp:uty Name or I C R i nt Name�(J( lSll4'L�ll r k <'l'
Nu. n Street® 60 3/ r! Email address
_Ci ./fotvn $t_at_"ZIP Tele hone/('
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:e.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 Istuance 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
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
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.
Kk,�) ftitl��u�
Print 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.eov:'oea Information on the Construction Supervisor License can be found at wtrw.mass.��ov�!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. 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 ofcooling system Enclosed Open
1. "Total Project Square Footage may be substituted I'ur"Total Project Cost"