25 CLEVELAND RD - BUILDING PERMIT APP (002) The Comntonwenllh of Massachuscus Town of
Board of Building Regulations and Standards
Massaehuselra State Budding Cade, 1g0 C HR, 7a edition BmWing Dept
• Application To Construct. Repair. Renovate Demolish a 4Y1�
Building Permit
One,yr Too.rtmrh'Dnr)lfng'
This S�+ion For 0 is! Use 0111
D to lip,
®u+kling Permil Number' D
0 --
Sig:atare: of gmldmka t _
8uliding Commissioner/Intlrce _
SECTION 1:SITE 1 O ATION .,_..------
1,j Propeeyy Address: I.Z $Mason Map Pareel Nuinbera
;( �C'eI: LF•C.9��'`�� t94 MaIIIIII Forest Number
I.la 11 this an accepted sttentr Ye+ _ no
➢.d Prdperry Dlrneosloea:
1.3 Zoning laformst➢arc _
4�:eg Drama M
13 gagdliag Setbaelts(n) Rerr Yard
Front Yard Side Yards
provided
Required Provided
Wcewned Provided Requrted — •^---�""_
Zoe rm ➢ 9Storage DisposalS
I \T/ rSupply:1M.G.1e.40.;54) 1.7 F7 on silt diapossj system ❑
deot �� F � Mmicilow ]
PI 13 Private thaek ifrq,c10
SWT➢ONIt PROPEnyyOWNERStfe•___�/7_
i.➢ i)wnertofRecord: /�a �uSrl•( S— ��r'y�=�N� v`Q'�O
�pHMtS9NICF e7 � A��gK. ervicr.
Narne(Pnnr _ _97�- 7�y_ SOd 3
teltpbane
HjVolum"
SECTION)= DESCR➢PTtON CiF PROPOSED WORKadeNrek all tel apply)
New Construction O Existing Building Owner•Oecupitd ® Repsirs(s1 0 Alteratiert(e) O Addition O
Ocher txc+%' LaF i To L r 11vsF
Demolition O Accessory Bldg.13 I Nr�ber at Units
A A F r F
Brief�HGriptign of Prop .Work : n.•F
�pvF_IIT��/tl?O FrYIS(Ti/fG�MaSo�TRY�^�/ `. t� w�
SECTION d: ESTIMATED CONSTssc)CTION CTbST�_
MS
Estimated Costs: 0mciat lite Only
nemLabor and �NatentlindisalahoS 1 Building Permit Fee S
OStondod C.ityRawn Application Fee
�._ $ 17 7ou➢Ptd1Kt Coat'(item 6)a muluplie3 Ptlr5 Z. Other Fees:List:ACI S Slfcc S Total All Fees: S ..r.�!/ Check"70 Check Amount CashTonoal: E lO Jy, $'+0 17 Paid in full ❑OWxumting Balance O4e'_
.a (P a� � owOWJ
U9i01i2009 12:23 9787409846 r.iirur JNL.G'I .._._.
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL) 3 2 76-0 /o /5 G 5
,L�- o ki9/20f7.jf:l &S0A/ Jot LwcmeNumb& EspuanonDant
Nyx of CxxL�Holder
1 S Der t/1/.<j//v 4.�t CSL Type(we below)
Addrese &y N Vi=O S -nzq n/ _'2 3 r Dt5[nPlinn
. p U Unresnlcled1ua1Q W0C'u.Fr.l
u RCsniNrd tAll Fam+lz_D.sellmd __
(y�r _ Masonry Onty
�7- S-S /o a RC Rcitdennal Roofing Covering _
Tttephome ',s'S Rcudrnual Winds.and Srdm
SF Restdroay5.A Fuel Burn;- A fiance installation
D Residtetwl[kmolittan_ _
S. Registered Home Imp oteracid neraetor(HIC)
O wrq 2DA. rqG� oA( r
HIC•'om y Name ar.HIC Rcilistram Nsmr Regianatltat Numhar
—10 iC r /M6,_5T 019A/vyl15
Ada-a
j7ZzI ,-6 2 expiration Dete
r5igru'vre.ry -�t--7 Telephone �^
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.t..c. IS2.ffi 3SC(6))
Warken Compensation Insurance affidavit most be completed and submitted with this application. Failure to provide
thin affidavit will resole in the denial of the Issuance of the building permit.
Signal Affidavit Attached? Yes........,.Q No...........❑
SECTION Tat OWNER AV THORIZATION TO 9 COP9PLETTD WHEN
q_wN ERIS A P�CONTRACTOR APPLIES FOR RUILD/NC PERMIT
Q _
11,_—\ I - 04,42:Z ,, as Owner of the subject property hereby
\4 authotiee __ to met on my behalf,in all matters
. ..—
relativs t o it authorized by This building permit application.
) M G
I-S, _C _-. �r __ �Oaray..., _._ —� .r,...
SECTION 7b:OWNEW Olt AUTHORIZED AGENT DECLARATION
as Owner or Authorised Agent hereby declare
that the natemcnU and information an the foregoing application we true and accurate.to the best of my knowledge and
behalf.
PriniNanNanle -
Siunsiurr oro finer or Authorized Agent i AN --
Si maunder the aaina and aenahica oraeriuty�
NOTES.•
I. An Owner who obtains a building permit to do his/her own work.or or m owner who who hires An unregistered contractor
(not Ixgisiered in the Home Improvement Contraclor(HIC)Program),witl agil have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information up the HIC Program and
C pervisor Licensing ICSL?can be found in 7110 CMR Regulations 110 R6 and 110.115,respecn.ely.
2, wher substantial work is planned.provide the information below:
Taal non,area ISq. Ft.l _ (including garage.finished basement/anics,decks or porch)
I Cross living area IS®. Ft.) 4abitable roam count
I N'umberoi'firrplaces .Numbtrafbedrooma.
Nu mbel of bathrooms Numb,,rr of hal(.baths
Typo o(heanrg system T Number ofdeckm porches —_____,___�
Type orcosling eyslem Fncw.cd ___Open
3_'Total Pre)ect Square Footage"may ht.uh,muled for"Total Pro)cct Cow"