2 CLOVERDALE AVE - BUILDING PERMIT APP • � ( � St,� �-K• I (��o-7
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
CITY OF
EM
Massachusetts State BuildingCode, 780 CMR Sd Mar
Revised Mar 2071
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
O This Section For Official Us my
Building Permit Number: Date App 'ed:
Building Official(Print Name) Signature Date =
(1 SECTION 1:SITE INFORMATION v
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers p- CP
1 2Cleurrdnllo Gue.
0
>� Lla Is this an accepted street?yes ✓ no Map Number Parcel Number ua t
1.3 Zoning Information: 1.4 Property Dimensions:
D r
MCZ
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) w
Front Yard Side Yards Rear Yard - v'
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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of 13,ecord: .
LLrtuiere Kec+t2C Tru' (Janet Larknere 'a-,Lm - wk plctio
Name(Print) ICity,State,ZIP
2 ClWe(Aal bw, C112-141.282?f
No.and Street Telephone Email Address
-- SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) d I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work : 2.h3 Cyr bathrinN - rr_m"-lnit.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ '� �cf� t 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ ., 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �j/ 3��1_CAD ❑Paid in Full ❑Outstanding Balance Due:
�� t�� 13" U-N q13
_ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /tyv�� Lt�.�.� y� 1 , Please Print Legibly
Name (Business/Orgmization/Individual): BF IIIL►r()Nsa t tUM6jnq A HCZnq
Address: T1 Holten Sf.
City/State/Zip: UdY-%\Xm . MA ONVI Phone#: 9•lfi' 1-14.3114
Are you an employer?Check the appropriate box: Type of project(required):
I. V 1 am an employer with- 4. 0 1 am a general contractor and 1 6. 0 New construction
employees(full and/or part time)." have hired the sub-contractors 7. ❑ Remodeling
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. employees and have workers'
[No workers'comp. insurance comp.insurance. $ 9. O Building addition
required] 5.0 We are a corporation and its 10. 0 Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work officers have exercised their
myself [No workers' comp. right of exemption perm MGL I I. tll Plumbing repairs or additions
insurance required] t c. 152,§ 1(4),and we have no 12. 0 Roof repairs
employees. [no workers' 13. 0 Other
comp. insurance required.]
'Any applicam that checks box HI mast also fill out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing as work and then hire outside contractors must submit a new affidavit indicating such.
tConmctors that check this box must attach an additional sheet showing the name ofthe sub-contractors and state whether or not those entities have employees. If
the sub-co tracmrs have employees,they most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:ri 55oettated Empleuers IhS CO
Policy#or Self-ins.Lic. #: WCC 501 001 201 2015,. Expiration Date: bl l 1201b
Job Site Address: 2 CkhAirzace.f.G. &I City/State/Zip: cC - M 1-iA G1G'71�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration (date).
Failure to secure coverage as required under Section 25a of MGL 152 can lead to the imposition of criminal penalties of a fine
up to$1,500.00 and/or one year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification
I do herby certify under t�heeppains and penalties of perjury that the information provided above is true and correct.
Signature �f �/ l/ Date'
Print Name' &an F 111u rgbU Phone #: q'1Q'•`11 t4 ' 31'f 4
Official use only Do not write in this area to be completed by city or town official
City or Town: Permit/license#:
Issuing Authority(circle one):
l.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact person: Phone#:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
t� C5-a13315 Cil3llb
�. CV1tiV QhU License Number Expiration Date
Name or CSL Holder
List CSL Type(see below) LS..
1% Ken mare br
No.and Street Type Description
U2YS. �1� iaG23 U Unrestricted12 Fu el ing cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
�$'ll4.33 33 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(MC) -119 lit,
I]Pa.L1S KA:awn a en, r HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
7Z 1,-Dien Si .
No.and Street Email address
-,L)Irxuara, FAA [y\�i23 t'il$ flak-3j33
City/Town,State,ZIP Telephone
SECTION 6:WORKE.RS'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 .......... Qt No...........❑
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' 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.c. 142A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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.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"maybe substituted for"Total Project Cost"
85"
68 , 16,6"
48" 37"
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All dimensions size designations Browns Kitchen Bath This is an original design and must Designed: 8/6/201`
given are subject to verification on 15 Elm St. not be released or copied unless Printed: 8/6/2015
job site and adjustment to fit job Danvers, MA. 01923 applicable fee has been paid or job
conditions. 978-774-3333 order placed.
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