10 CLEVELAND ST - BUILDING INSPECTION (2) ��� 7 . --- I'he C'ummunrvuahh u('�blassaehusclls -..
Board of Building Regulations and Standards Cl FY OF
t
10assachusetts State Building Code, 730 C NIR SALEM
HVI-A"d Ila.2011
Iltllding Permit Application 'ro Construct. Repair. Renovate Or Demolish u
One-or Tu o-Pinnih' Duelling
This Section Fur Olticial Use Only
Building Permit Number: Date,\ plied;
UuilJiny URieial(Print N�unu) Sigrnu urc Dale
SECTION 1: SITE INFORMATION
Pr 1'] 1s°essu � ep SParcel Numbers o7vfkTA1dS /
I.1a Is this aannaccepted
street?yes no 1 ,%lap Nunlxr I'urcel Nnmlrcr
I.] Zoning Information: 1.4 Properly Dimensions:
luring District I'ropnsuJ lJxeLal Area(sy 11) Frontage(II)
1.3 Bullding Setbacks(R)
Frun:Yard Side Yards Rear Yard
Required Provided Required Provided LRcquimd Provided
1.6 Water Supply:(M.O.I.C.40.1]a) 1.7 Flood Zone Informallont 1.8 Sewage Disposal System:
Ribl(c❑ Privule❑ Zone: _ Outside Flood Zone?Check if us❑ I Municipal❑ On fib disposals)stem ❑
ECTION2. PROPERTY OWNERSHIP'
2.1 wner4ofRecords /
N;ane(Print) //,p . T City. tale,ZIP //��/'y� 7
/L c/ 1. ue / uk_ / l� aill-335 :2 P lesz62ttNslt LSCJ tmm 0SJ r
No.and.Slreelfulephune Finail Address
SECTION]: DESCRIPTIO)N OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building 01 Owner-Occupied 0 Repair (s) Erl Alteratlon(s) ❑ Addition ❑
Dennulition ❑ I Accessory Bldg.❑ 1 Number of Units_ Other O .Spud ly:
Brief Description of Proposed Work,:
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Laborand \I:uerials) ny
1. Building I $ 1 I. Building Permit Fee: S Indicate how lee is determined:
_'. lilvclrical S ❑Standard CityrTusrn Application Fee
❑Total Project C ost'I hens 6).e multiplier
), I'lumhing 5 ,. OnhcrFees: S _ -
J. Mcch.mical ill\ \('1 S Lisl:
l �n 1eJ1 iom S rpt:ti \Il Feel: S
Chat No. ( heck Anunml: C.uh \mmwc
o rural Project Cost: i nn,� --
(✓C (J 0 hid in Full 0(Austmding B,l•unce Due:
SECTION i: coNS rRuc-riON SFRVICFS
5.1 Construction Sullen isor License SI-)
i,\pir;R11111 DalyI ceosc Number
I [M('St. I'MIC Isee
I PC Dcs�ripilon
N11-311d.Slrvd Inresiriocd(Ilm Idin-s 10 1%)3;.000 a1- 11.1
It liciriocd Nt-2 I:alllil Doctlill
40,00ll.Slate. %I Melon
RC Rootin Onvrin
AS Window old Sidill
SF solid Fuel llurnin#Appliances
I 111sul.-lion
1'dc how I:mail addrvm D Demolition
5.2 Registered flume Improvement Contractor(HIQ
IIIC 111cilibiraliun Number F\Iiirnlion Date
IIIC Compin) Mane of IIIC Registrant Nwoo
No. and Street Finail address
CiryfTown.State,ZIP Tele hung
SECTION III WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 133.1 25C(Q)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atTidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........Cl No...........(3
SECTION 7a:OWNER AUTHORIZATION TO 139 COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
print Owller's Nunic(Electronic Signature) Data
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering i ne be] I hereby attest u the pains and penalties of perjury that all of the information
3 Ira
contained ' is alio s Ira accurate the best of my knowledge and understanding.
Dow
NoIllri1v , I , .•.Sin. I :a/ I
Print let'i i loithorin , gv,16 Mona I Si nalore
,NUFES:
[L :An An %Oooblains a building permit to do his her u%vn work,or an owner who hires an unregistered cunlractor
JIM registered in the Howe Improvement Cuntractor(HIC) Program).will 1a) have access to the arbitration
program or guaranty fund under.M.G.L.c. 142.4.Other important information on the HIC Program can be flound at
I Information on the Construction Supervisor License can be found at—%�k 11T3,; �i,,% 41,
2.
When substantial work is planned,pros ide the information below:
en U
totalItio .11,4. 11 attics.dc"i or rorchi
o(al flooraren I s4. tl I garage. finished basement
a of are Ilabilable rouill count""" I" ",at u I
Grois li%iogareafi+ ll.l
\t1Jl)l,Vr 0 I'll rVI'llIcONumber of bedrooms
Nimillcroftlathrooms Number of half hailli
I)Ilk:of heating i\,Ieln
f\pe .t COUhlig i1 ilcill .01'ell
1. A o1al Sklllarc I:klolagc- ila\ IV killsiltutcd 111r-total Proicct Olit-