25 CLEVELAND RD - BUILDING PERMIT APP The Commonwealth of Massachusetts RECEIVED
� Board of Building Regulations and Standards INSPEC TIONAMMVIC SSALEhI
Massachusetts State Building Code, 780 CMR vised A A rr 2011
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Building Permit Application To Construct, Repair, Renovate Or Demolis�� Fe b: 04
One-or Two-Family Dwelling
This Section For Official Use Onl
MBuilding Permit Number: Date A lied:
Building 011icial(Print Name). Signature• Date
1 SECTION 1:SITE INFORNIATION'
1.1 Property Address: 1.2 Assessors blap&Parcel Numbers
crf C r3
1,[a Is this an accepted street9 yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
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❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P
SECTION2: PROPERTYOWNERSHIPt'
2.1 Ownert of Record: SQ�� mk d1176
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��hme(Print) City,State,ZIPS
aSe � R4 a
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building O 1 Owner-Occupied ❑ Repairs(s) j7 Alterotian(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ I Number of Units I Other ❑ Specify:
Brief Description of Proposed 1Vork': L c
�ic�_ r�pr9L[T �F Stllr4l�rES.
d 1/Lwfi B /fey10/16
0(p;S
SECTION 4: EST16fATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
�I. Building I. Building Permit Fee:$ Indicate how fee is determined:
$ ' ❑Standard City/Town Application Fee
2. Electrical 5 ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S P Qther Fees: S
4.Mechanical (tI VAC) S List!
5. Mechanical (Fire S Total All Fees:3
Suppression)
Check No._Check Amount: Cash Amount:_
6. 'fatal Projcet Cost: S ❑Paid in pull ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES r
5.1 rC,onstruction Supervisor License(CSL) � 'N'
J(j� m AtI� LicensL NIImFber E.e trau n Date
Name of CSL Holder
1 List CSL'fype(see below)
Type _ Description
No.and Street
// �,/ ,M /y U Unrestricted(Buildingstip-to 35,000 cu. Il.
�"�'eoa r MA o 66 R Restricted M2 Famil Dwelling
Cityfrown,State, IP M Masonry
C Roolm Covering
S Window and Sidin
F Solid Fuel Burning Appliances
q7g-631- 9 1 Insulation
Telephone Enmil address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
(A N I! rlatl r4N)17kkt' I' C Registration Number E irut' n Date
HIC Company Name or HIC Registrant Name
�a��if IT '
No ;d Street Email address
a�- r AA ^IR�o
Ci /Town,Slate,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.15L§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 Wtiance of the building permit.
Signed Affidavit Attached? Yes ..........)!k No...........❑
SECTION 7a:OWNER AUTHORIZATION,TO BE.COMPLETED.WHEN'
OWNER'S AGENT OR CONTKACTOR APPLIES FOR BUILDING PERMIT'
1,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) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
coat.fined in this application is true and accurate to the best of my knowledge and understanding.
.> Mw4ffmd y9-7-/5
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 noI have access to the arbitration
program or guaranty fund under N.G.L.c. 142A.Other important information on the HIC Program can be found at
www m;Lss.cov'oca Information on the Construction Supervisor License can be.found at www.nmss.eo+:'Jos _
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) `a .'(including garage,finished basementlattics,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
i. "Total Project Square Footage may be substituted for"'rot:d Project Cost"