11 CLEVELAND ST - BUILDING PERMIT APP The Commomvealth of Massachusetts
Board of Duilding Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revi.,ed,Nar loll
One-or Two-Family Dwelling
Building Permit Num ber: '"Section For Official Use Only
to A lied
f
Building Official(Print Name),
Signature Date
SECTION I:SITE INFORi�fATION'
1.1 Pro ertyy Address:
/ 1.2 Assessors Map&Parcel Numbers
I.I a Is this an accepted street?yes �no_ blap Number
1.3 Zoning Information: = I a._e.Number
1.4 Property Dimensions:
ZoningZoning D- I�— proposed Use
Lot Arca(sy It) Frontage(It)1.5 Building Setbacks(ft)
Front Yard Side Yards
Provided Re
Require) Provide) Rear Yard Required aired
y Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information:
Public❑ Private❑ Zone: _ Outside Flood Zone? l•8 Sewage Disposal System:
Check ifyes❑ Municipal❑ On site disposal system ❑
2. Owner'of Record- SECTION2, PROPERTY OWNERSHIP'
1
il5me(Punt) �i�P� �� ry!•P ?e
City,State,ZIP
7 9V No.mtJ Strcel
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check ail that apply)New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units
Brief Description of proposed SVork': /iyr��� Other ❑ Specify:
G—
�1/•//'I,,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: �—
Labor and Materials Official Use Only
2.
Building ,; � I. Building Permit Fee:S - Indicate how fee is determined:
Electrical S ❑Standard City/Town Application Fee
3. Plumbing S ❑Total Project Cost'(Item 6)x multiplier x
2. Other Fees: S
4. \,I 11,mical (FIVAC) S List:
5. illechanical (Fire
Su )ression) S "Total,111 Fees:S -
6. Total Project Cost: S �/ � — Check No. Check Cash Amount:
❑PaiJ in Full ❑Outstanding Balance Due:
i
ncc�/Cc f
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) License Nuliver Expiration Date
W� " C
/ Arc r
Name of CSL Holder List CSL'rype(see below)�—
.�ype. ' Description .
Cz�� 2r f�
D Unrestricted Buildin s u to 35,000 cu. IlJ
No. and Svcct Restricted Dwellin
R
I&2 F;unil
l—k- (hJ ///? — M Mason
Cityfrown,State,LIP RC Roolm Covering
WS Window and Sidin
Solid Fuel Buming Appliances
I Insulation
;>-o,L Sf D Demolition
Tole hone Email address
5.2Altegistered�Home Improm119 e��/tractor(HIC) HIC Registration Number Expiration Dade
w°�r
HIC Comport Name or HIC Registrant Name
�o,y,y � Email address
No., id Street o 59e7�iJ7% -o,z
Telephone
Ci /Town,State ZIP
N INSURANCE AFFIDAVIT(M.G.L.C. 152.¢ 25C(o)):.
SECTION 6:WORKERS'COMPENSATIO mpleted and submitted with this application. Failure to provide
Workers Compensation Insurance affidavit must be co
building permit.
this affidavit will result in the denial of the Issuance of the
Signed Affidavit Attached? Yes ........
SECTION7a:OWNERAUTHORIZATION,TOBE.COMPLETEDWHEN: i
OWNER'S ACENT OR CONTRACTORR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work a uthorized by this building permit application.
S7eve ee� Z &7ylz� Date
Print Owner's Nmne(Electronic Signatur
AUTHORIZED AGENT DECLARATIO
SECTION 7b:OWNEW OR
N
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 of m�g�nCv%understanding.
d✓,'�/���v/®ilJ A*, Dam
Print Owner's or Authorized Agent's Name Kicciruik Siga 11- I Ll"&---
I. An Owner who obtains a building permit to do his/her own work,or ant°Ilneul havetaccess to the arbitires an ration
tractor
(not registered in the Home Improvement Contractor(HIC)Program),
_ informal ion l _Pr_ and a[
n l OSi td t _"ovt`Ity
mheCostrution upervsor Liensecanbe otn %vll
ws � i ve�Ifrmu on on
i. When substantial work is planned,provide the information nuinglaarage, finished basement attics,decks or porch)
"total tloor area(sq. ft.) Habitable room count
Gross living area(sq. ft.)-------- Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches
rype of heating system — Enclosed Open
rype Of cooling system
3. "Total Project Square Footage"may be substituted for"rotul Project Cost"