3 CLIFTON AVE - BUILDING PERMIT APP �\ The Cununoncealth 01 Massachusetts H)R
t HuarJ of Building Regulations and StanJ:ulds \It'VI( IP.\I.I'll
LMaSSaChtlSetts State Building Code. 7Stl CkIR, 7 edition 1 'Sli
Building Permit pplication To Construct. Repair. IZenocate Or Demolish a Rrru.,l.loSOne- ur T:ru-Fainily D)telling1. 'uu,\'phis Section Fur Official Use Only�` ng�Pernniiber: Date Applied: l
Signature:
Building Commissioner/ Inspector of Buildings Date
---I
SECTION I: SITE INFORMATION
LI Pr pert Address: 1.2 :Assessors :'flap & Parcel Numbers
l l kInn Are hue -
Lla Is this an accepted street? yes nu� Map Number - P:ocel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(f )
Front Yard Side Yards Rear Yard
Required Provided - -Required Provided Required Pnro idcd
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone.,
Public❑ Private ❑ Check ifyes❑ ,'vlunigipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
EOw ert of rd:
r�� (()Recoeco : 111 I I 3 LL i-F-bn AV�a�t rP
Nat mt - Address for
or Service:
A Siena Telephone
_ P
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) :\ddition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units- Other ❑ Speciry:
Brief Description of Proposed Work':
1 l VI
I
SECTION'4: ESTIMATED CONSTRUCTION COSTS
i Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ '7 D I. Building Permit Fee: S Indicate how Ice is determined:
❑ Standard. City/Town Application Fee
2. Electrical S ❑Total Project Costa (Item 6) x multiplier x
3. Plumbing 3 2. Other Fees: $
4. Mechanical (HVAC) $ List: --
5. Mechanical (Fire , ---
Su . ression) Total All Fees S
Check No. Check :\mount: ('ash
b. Total Project Cost:. $�' --
i J " I � [, � ❑ Paid m Full O OutstanJin��.Balance Uue:___
i -
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) 7
-/r hr'�P r License Nunthtt I{spu,uinn late ,
Hama of('SL- I folder Lot C'SI.T\pc (See below) --
TN e Descri turn
\ r s. L I, nrrslncted i I'll to}S.I()O Cu. FI.i
. R Restricted 1&2 Fanuk Dsrellule
Sienatu a -� \1 masons Only
12C Rcsldenual Routine CO\ei'Ine
telephone \VS Rcsuleiaial \\'nldo I\ .md S1dma
SF Residcini:d Sohd Duel liummc \tthanrc hnl,illauuie
p Iteadenual IJrmuhuon
5.� i't Regered home Improvement Contractor (IIIC) p)tocR
a `�P1_VI�TV1C
Rcgtsumiu❑ tiunther
111C Compan :dare or HIC R`glstrani Name
Addr Expiration Date
Sienature Teleph/phJne 1
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L.C. 152. § 2506))
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
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 - as Owner of the subject property hereby
authorize {���tD17�1 (-Z� to act on my behalf, in all matters
relative to work authorized by this building permit application. j
v 5_-
Si natureuf Owner Date
t,,, SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I r`I rl�'�'"7D�^1 i� ZDYZLA , 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.Print Namev r Z SW ID S
Signalu)- wner tr Authoriz d Agent _ Date
(Siened under the 2ains and penalties of eedu 1
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an caner who hires an um egi stercd cpntraaor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to.the :ubitration
program or guaranty fund under M.G.L. c. L32A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 C'MR Regulations 110.R6 and 110.R5. icspectively
' When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) - (including garage, finished hasemenUattics, decks or porclo
i Gross living., area ISq. Ft.) Habitable roc rn count -
Number of fireplaces Number of bedrooms - ---
Number of bathrooms Number of halt/haths -----
Number of decks/ PIrcchcs _—_---
rvpe of heating system U felt. _
_. . . r1'pe of cooling s)stem
[nc lased ---- -- -
J. "Total Project Square Footage- may be Substituted tier "Total Project Cost" j