6-8 CLIFTON AVE - BUILDING PERMIT APP L4 q
z5� The Commonwealth of Massachusetts
° y Board of Building Regulations and Standards RECEIV D CITY OF
j Massachusetts State Building Code,780 CMI� QF Rlxm
INSPECTIONAL 7evisedMar20L1
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling 714 A 5
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This Section For Official Use Only
Building Permit Number: Da Appfied:
) K
Building Official(Print Name) Signature at
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
6-9- C), (TGn AIC
L 1 a Is this an accepted street?yes 11*� no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
a
Zoning District Proposed Use 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:
PubliCt�, Private❑ Zone: _ Outside Flood Zone?Check if yopq Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: m ,^t
Name(Print) City,State,ZIP
A3 Naples 71P/ 9/0 9/I1V
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s)04 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : lV CA) i,9•n — Oa rune r S
QieoInce Decr g +/1cc t c 4 r S ioE G-- Ira nc e w P 1'G
SECTION 4:ESTIMATED C40NSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ T7 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost'(Item 6)x multiplier—� —x
3.Plumbing $ 2. Other Fees: $ f �
4.Mechanical (HVAC) $ List '�f-�C
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: $ '/ S�� ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
/J QS7a.S1 Sr'G—/S
&CICr..n A u r A-MO n License Number Expiration Date
Name of CSL Holder
n List CSL Type(see below)
Van✓ o,r s i
No.and Street Type Description
r U Unrestricted(Buildings to 35,000 cu.ft.
City/Town,State,ZIP
y/ JCrS �4 O l g d 1 R Restricted l&2 FamilyDwelling
Tow M Masonry
RC Roofirta Covering
WS Window and Siding
SF Solid Fuel Bunting Appliances
I Lrsulation
Telephone Email address D Demolition
5.2 R/e[g t�stered Home I7m'JFrovement Contractor(HIC)
Fit r r HIC Registration Number Expiration Date
HIC Co37y Name or HIC Registrant Name
S �nDaJPr s - S�tr,�n„Y�a�,,�svn e Sj' C
No.and Street Email address
-Oct Cyver- X—) r1/99M ® lb+rtrci, I. C6n�
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.........ARNo...........❑
SECTION 7a:OWNER A HORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize l'(0.r) D a U t
41al7
matters relative to work authorized by this building permit application.
S z B t
Print (Electronic Signature)
SECTION 7b:OWNEW 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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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.a 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 at wy .mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.fl.) 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"maybe substituted for"Total Project Cost"