2 CLIFTON AVE - BUILDING PERMIT APP YED
1'hr onmmonweal(h ofMassachusWSPECTIOJSERICES
Cf : oard t f 1uilding Regulations and Standards CI I'Y OF
Massachusetts State Building Code, 7S0 C ti,\LL\I
6 �� MAR evived.1tur 2nii
Building Permit ApplicationTo Construct. Repair, Renovate Or De
f` (Ale-or Tow-Famd.v Dmrllin.te
(1 rhis Section For Official Use Onl
(�1( Building Permit Number: ppl Date A ' d:,
— ���l 3 ��
In Budding Ullicial(Print Nmne) SignaTure Dote
SECTION I:SITE INFORMATION
L I Property Address: 1.2 Assessors Map& Parcel Number
I.la Is this an ucce trd street?yes no 1,11ap Nunthcr Parcel Numhcr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District P®poscd U c Lot Area(sq 11) Frontage 00
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Reyuircd Provided Reyuircd Provided Required Provided '
1.6 Water Supply:(M.GA.c.40,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Lune?
Check if cs❑ Municipal❑ On site Jisposul system ❑
SECTION2: PROPERTYOWNERSHIPI
2.1 Ow fit of eco�d,:
o 1MAUM1 ►c � o4t1►Pr.�l
Name(Print) City.State.ZIP -
2 61L -1 -0 5
Nu.and Snreel Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building( Owner-(Iccupied ❑ Repairsls) ❑ Alteraticn(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units-__ I Other Specify:
Brief Description of Proposed Work':_ t
ILI
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
I labor and.Materials) Official Use Only
i. Building S I. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S ❑Standard CityiTown Application Fee
j 1. Plumbing $
❑Total Project Cost'(Item 6).x multiplier --
_. Other Fees: S
a. Mechanical (ll%'.\(') S List: __
i9 \l. ecmowal (Fire S _ --
tietuessionl Toml .\IlFers: S_
Check No. Check,\ntauut:o. Total Project Crest: S 1,— v �� O Rid in Full ❑Outstanding Bal:mce Duc:
-Tb
SE("I'10N 5: CONSTRUCTION SERVICES /
5.1 Construction Supervisor License(C'SL) /02,213 /?� l�j 1
-- --- — --
Licenec Number Tgnrutitim Uate
N:unc ul'l'SL l lolder A� I iSt CSl. l')pe(Sec below)
el
No—ind Strout
I hvc 1 n s l to iS,In
^ Ml;40r1' Y R tntricted l&'2 Falmil 0 cu. Il.l
D��ellin
Cit\i rown.Stale.LlP ..-- M1I Mason
RC Roo io Cocerin
WS N'indo\r;md Si iol
q SF Solid Pu.1 Ilurning Appliances
L//I� S Wr, 0 l�(0,f r 1 Insulation
l'cic hone (mail aJ \ss D Demolition
5.2 Registered Home
,Improvement Contractor(HI
(14ASS W k "' , t Ut 2. ' 4G� 1IIC Registration Numlxr lis irni m Dote
I IIC comps) N;me or IIC I 1 t antNanu
cak
No.in
•yk•t �,An p�� (7�d �`�Y�'�[�/' 7� Emm address
City/Town.State,ZIP , t Ofelc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.1 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 A THORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR
BUILDING PERMIT
1,as Owner of the subject property,hereby authorize Pt(—M
to act my ehalf, 'n all matters relative to work authorized by this building permit application.
e-yY,l,LP-->7 3 z 6 /
J'J
Print Owner's woe(Electronic Sigmnure) ate
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
Contianed in this application is true and accurate to the best of my knowledge and understanding.
Z — � /S'
Print Owl er't or:\uthoriM Agent',Name Micctrunlc.Slgnaulrel Da '
NOTES:
I. An Owner who obtains a building permit to do his•her own work,or an owner who hires an unregistered contractor
1 not registered in the Home Improvement Contractor(HICI Programl.will no 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
„W% IIA" % ,,,,1 Information on the Construction Supervisor License can be found at )\ ).nl.l.:�_n -lily
2• \\'hen substantial twrk is planned, provide the information below;
rota) floor area(sq. 11.1 _ 1 including garage. finished basement attics.decks or porch)
Gross liv ing area I sq. Il.l Habitable room count
- --------- -
\timberof fireplaces__.. — Numberol'bedruoms
\'umber ol'hathrooms \'umber of half hoths
1'\lie of heating system \umber ofdccks, porches
i
I\pe of c.+ohng ivstent Flwlosed Open
1. "fatal Proiw Square Footage"may he iuh;tituted fir"Donal Projeo Cost"