10 CLIFF ST - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
V Massachusetts State Building Code, 780 CMR, 7'"edition MEMO
Budding Dept
n I Building Permit Application To Construct, Repair, Renovate Or Demolish
One- or Ttco•f r u ling MEMO
This 5c6lion For tcia Use Only
Budding Permit Nu
Signature:
Budding Commissioner/ nspect of is m Date
S CTION I:JJIiT&4NFORMIATION
I.1 Property Address: 1.2 Assessors Map 6 Parcel Numbers
C 1
�O G6 c-T
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided RequiredProvided
1.6 Water Supply:(M.G.L c. 40,l54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check if es0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: t
fH(" 1- , -.r SZ'. 6e -Li l-=� C 'G/ ri
Name(Print) Address for Service:
C
Gr?-33s- ssc I Celt
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction D Existing Building O Owner-Occupied O 1 Repairs(s) O Alteration(s) O 1 Addition O
Demolition O Accessory Bldg. ❑ Number of Units_ Other Nl•Specify:
Brief Description of Proposed Work :
er.�9 F — /'eS-k'i,l.�T' t n iTfrL 1 -
M�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
$Buildingg f I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
al S 0 Total Project Cost'(Item 6)x multiplier x
ng f 2. Other Fees: f
ical (HVAC) S List:
ical (Fire Son Total All Fees: f
Check No. Check Amount: Cash Amount:roject Cost: S 5-a- ,Z 0 Paid in Full 0 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed
(�Construction Supervisor(C
SL) , Ll r
�• L-L. A Z ,S Pmt Nom'
License Number Expiration Dam
Nyoe of CSL Hglder N l ✓9 List CSL Type Oee below)
AC �
T Description
Address Unrestncted Iup to is(M Cu. Ft.)
R Restricted 1&2 FamilyDwellin
5ignnure q .N %lasonry Only
U'T✓ RC Residential Roaring Covering
TelephoneC WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 'I S�
i 12'26 - S'a �.v ��-�
HIC Comp ray Name orTC,Regi51rrl Name Registration Number
Address p L( "d J I\
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 157.S 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 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
( 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, - p Sin ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Ae��r,
Print Name
Signature of Owner or Authorized Algent Date
Si reed under the pains and nalt' s ofperjury)
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 ray,(have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/anics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage'may he uhst uuted for"Total Project Cost"