3 CLIFTON AVE - BUILDING PERMIT APP (004) i 1
The Cumrnunstealth ul Massachusetts H)k
_ Fiottrd of 131.111dint; Regulations and Standards \I( NI( l,l'.U.I'll
t.' MaSS:tlItLISCUS State Building Cute. 7S1) (Tx-1R. 7°i edition til[
p, R,rocd loww,o
� BuilJim_ Permit Application To Construct, Repair. Renos:ur Or Demolish a / ,I tae
Om- ar Tina-Fa mill- Do(4/iat,q -- -�
This Section For Official Use Only
Building Pennit Numh Date Applied: — _-------- _.-�
Signature:/ ----------
f3ui ineC'unuunsioned lnspcctur ul Buildings Umc
SECTION 1: SITE INFORMATION -----_._-,
1.1 Prope t�' Add Ss, 1.2 Assessors Map & Parcel Numbers
i / I '�ar n f`P Y)UJ _ ----
l.la Is this an accepted street? yes f no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage iitt .
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Pru%ided
1.6 Water Supply: (M.G.L c. 40. §)4) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone" Municipal ❑ On site disposal system ❑
Puhlic Cl Pro vate❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2 1 Owner'of Record:
��22,,--,,�� 6 NQY1(s! Add r SCrvice:�
Name _ o J /� O 7p!
�w� ��. �it% Telephone
70 714� Oy 1
Signature
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units - Other ❑ Specify:
r Brief Description of Proposed Work'':
e GJ/ �hC7/
� r -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials) —1. Building Building 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town :Application Fee
2. Electrical ❑ Total Project Cost' (Item 6) x multiplier x _
3. Plumbing 5 2. Other Fees: $
List:
J. Mechanical t HV':1C) -
S. Mechanical (Fire S
'fetal All Fees: 5
Check No. Check ..Amount:
j b. Total Project Cost S ❑ Paid to Full ❑ Outsumding Balance [due:__
OU
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Constnictiun Supervisor (CSL) '
-�h"P (-y Llrc'nsc N'uuther livhlr mon Date
Name ofCSL- IIuIJcr
C � L.I>I CSL"I'\hc Ire hrlurole-f
\JJrrs. `J t Tv c Drc:ri lUon -
( Lllll'$IIle1CJ fill it11i"000Ctl. 1'1,I
- R Restricted I.@'_ Famil\ DlNclhne
S mall re \11 Mason(\ Only
7� 12C 12chlJautlal Kuuting Cal cane
1l•kphune \\'S Ite>IJcuual \\'ntdu�l .Ind SIJIne __
S1- Rc>I&Iltial Solid Purl Burnme \ 1lllancc hl.l,tl Lunn
D Ra.Idotwul Demulitwu
5.� Registered Ilome Improvement Contractor 011C) Ian �P GI
f) SP /l( P 1h --
HIC Colup;my N:unc or HIC Re tstrm Name Registration :Number -
Ad re s
b/a(0(t'
--E, pt�D:uc
. Slgnrt re V - Tciej,hone
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 r
1. 17Qh OY as Owner of the subject property hereby
authorize Chr �27 17� 7..fl' r -� to act on my behalf. in all mallets
relative/to�work authorized by this building pe it application.
Slgnaturc tit Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
[• j S''"'�f'�{71/jQ �[}{'—�� , as Owner or Authorized Agent hereby declare
that the statements and information on t foregoing application are true and accurate, to the best of my knowledge and
be If.
r
Print .\alit h)
Signaulre of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered cumractor
(nut registered in the Home Improvement Contractor (HIC) Program). will not have access to the tubitraliun
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 750 CMR Regulations I I0.R6 and-I I0.R5. respectively-
'. When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including uarage, tinished hasement/attics. decks nt porch;
(iros.c living area tSq. Ft.) Habitable morn corm
Number of fireplaces Number or hedrnom, -
Number of h:uhrooms Numher of half/huth, — __----—
fvpe of healing sysrern Number nt decks/
Tgpc otcuoline system_ FncluoeJ Open —
3. "Toull Project Square Footage" may he substituied for"Total Project Coot'
_J