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3 CLEVELAND ST - BUILDING PERMIT APP The Commonwealth of MassachdsMECTI I $ERVI ES Board of Building Regulations and Standards CITY OF ,I,A,� Massachusetts State Building Code, 78 l SALEM 'rC ,YOW �S P 3: 7Zevised Mar 201l Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling-This Section For Official Use Only Building Permit Number: Date Applied: _ Building Official(Print Name) Signature 4 D _ SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers t�•j`-\/ 1.1 a Is this an accepted street?yes no Map Number Parcel Number L1.3 Zoning Information: 1.4 Property Dimensions: Ib _ Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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 ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner[of Record: f 0 W t C.-L frs -�!!'t9 01C 1 70 Name(Print) City,State, f' a Kieyri& < it ��8 ne 2 Saz9 No.and Street Telepho Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other G-Specify: Brief Description of Proposed Work': SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: — Item _= Official Use Only .F Labor and Materials - 1. Building $ 1 Building Permit Fee:$ Indicate how fee is detennined: 2.Electrical $ ❑ Standard Cityi Ibwn Application Fee ❑Total Project.Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ression Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ h V Q�� ❑Paid in Full ❑Outstanding Balance Due: — �7 H • O - M t_ 'p �$ /\N SECTION 5: CONSTRUCTION SERVICES S.I Construction Supervisor License(CSL) o86L'Do NaTICSL Ho�Ga License Number Ex D ate List CSL Type(see below) tIJ No.and Street Type Description N1� [�3 D j(� U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Coverin WS Window and Siding SF Solid Fuel Burning Appliances f� 7rP y o z3.- A40/t C. ,JanO P_L.—Cu I Insulation Tele hone Email address �' D Demolition 5.2 Registered Home Improvement Contractor(HIC) / l� 3yo� � /6 / A7 t,.t! p fo f ofk 6 -&hnr, HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name /4.1 2 f J 4.A A A/ h01_...11 t.,e Sv. r �Lone...f e_ No.and Street Email addres(s r � E L_ Ni f4 ©J 0 7t6 )A o4 o Z�S Ci ITown, Stale,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 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 Issuance 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 Ta kn /-Abi yc// to act on/f at my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name( IectroniI'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 contained in this application is true and accurate to the best of my knowledge and understanding. 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/oca Information on the Construction Supervisor License can be found at www.mass. o€: v;dns 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.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 be substituted for"Total Project Cost" -