15 CLOUTMAN STREET - BUILDING PERMIT APP i
1 f a The Commonwealth of Massachusetts
j Board of Building Regulations and Standards CITY
`1 Massachusetts State Building Code, 780 CMR, 71"edition OF SALEM
Revised Jumurrt'
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 2008
One-or Two-Fumdv Dwelling
This Section For Official Use Only
Building Perm't No er: Date Applied:
Signature: t_ J
Buil in m issi 1 ' •tor of Buildings Date
SECTION I:SITE INFORMATION
1.1 Property Address: / 1.2 Assessors Map& Parcel Numbers
i S L%✓�-�/�.J C.Aw� S A _
L l a Is this an accepted street?yes f/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lol Area(sq R) Frontage(11)
1.5 Building Setbacks(it)
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:
Public O Private❑ Zone: _ Outside Flood Zone?
Check ifesO Municipal❑ On site disposal system ❑
2.1 Owner'of Record* SECTION 2: PROPERTY OWNERSHIP'
�^
i"q-r4fC rt COOAXd rJ 15-
Name Aint) Address for Service:
979-.�YJ=z13 7
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 A dition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Speciyxi/ISve-M'Ic '
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 11. Building Permit Fee:S Indicate how fee is determined:
2. Electrical $ ❑Standard Cityfrown Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S 11/'
4. Mechanical (HVAC) S List: l
5. Mechanical (Fire S
Su ression Total All Fees: S
v v Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ��(f 0 Paid in Full 0 Outstanding Balance Due:
r r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.icense Number Expiration Date
Name of CSL- I folder I-ist CSL Type(see below)
'F Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Rooting Covenn
Telephone INS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number _
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 .......... 0 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 S as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application. -
Sianature of Owner Date
(^� SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
r c�CnC 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. 6 JJJ
Print Natp � � � �,p
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 nyj have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115. respectively.
? When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,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"