6-8 CLIFTON AVE - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts K M%�
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Board of Building Regulations and Standards INSPECTION L S
Massachusetts State Building Code, 780 CMR : Revised Mar
11
Building Permit Application To Construct, Repair, Renovate Or DMiNOY 2 4 AD 32 ,
One-or Two-Family Dwelling
M This Section For Official Use Only
Building Permit Number: Date lied
!/
I Building Official(Print Name) Signature .to
eT ly
SECTION 1:SITE INFORMATION
roperty ress: 1.2 Assessors Map&Parcel Numbers
^Sr Fran /{mot.
.1 a Is this a pted street?yes t/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Gx,S r...& Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public4— Private❑ Zone: _ Outside Flood Zone?Check if yes® MunicipaLFrOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Name(Print) City,State,ZIP
' II L+ale Na1arR.l VW-?9Pk*-str �oe.+iocuct�rrasr,nl
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs( Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Wo/�rk2:
A P 67t 'L 91 �cn CAAS. i n
No wa11 Demti Gn s1 La dr. Ao^ rn
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ /G p0 6 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 $ 2. Other Fees: $ k
4.Mechanical (HVAC) $ List: U
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ /G Oa0 ❑Paid in Full ❑Outstanding Balance Due:
fllAlt�7� ab CpIJT 11 �Z�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
I9/'10Ln I040tntr) License Number Expir io ate
Name of CSL Holder
,t List CSL Type(see below) �-
�andS I�M OOJIr• -ST Type Description
No.and Street
U Unrestricted(Buildings up to 35,000 cu.ft.
JCZ✓1J @ v-)A- CY513 R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Mason
RC Roofing Coverin
WS Window and Siding
n SF Solid Fuel Burning Appliances
/kl �ftly 47 (.-t'6�,%tea. I 1 I Insulation
Telephone Email address 'er'l D Demolition
5.2 Registered Home Improvement Contractor(HIC) i�J 8J3—
�,
Pr a n bQ V 1 IMC 01-, IBC Registration Number E irati n Date
HIC Company Name or HIC Registrant Name
rGq tan DU 7C sT
No/..(d Street Email address
City/Town, State,ZIP Telephone
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
I,as Owner of the subject property,hereby authorize 9 r I Cl ,/
. d n
to act on my behalf, in all matters relative to work authorized by this building permit application.
\
}.... / / /
Pint Owner's Name(Electronic Signature) Da[
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
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 best of my knowledge and understanding.
� 0�6_� / 2t,
Print Owner's or Authorized Agent's Name(Electronic Signature) Vale
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 not 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
www.mass.gov/oca Information on the Construction Supervisor License can be found atwww.mass.gov/dy
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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