15 CLOVERDALE AVE - BUILDING PERMIT APP (002) (0 S l G K l-'tSb 1 I ` -0
The Commonwealth of Massachusetts
W
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Retied Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
j —0,6 2, One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pli :
Building Official(Print Name) -signature Date
SECTION 1: SITE INFORMATION
1.1 Pr pertyG��ress:A 1.2 Assessors Map&Parcel Numbers
l.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sgft) 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:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
.Check if.es❑
,p �p rd
SECTION 2: PROPERTY OWNERSHIP'
2.1 r1[ e4 � i9
otuv
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alt ration s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of U -ts Ot er pecify: ,
Brief Description of Proposed Work :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ -7 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $
❑ Standard City/Town Application Fee
❑Total Project Cose (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: $ 7300 ❑Paid in Full ❑Outstanding Balance Due:
�6v�,e60�
.SAY
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Super�v�1sor License(CSL) `VD- 7) !l G�
1 t�V ✓ ` V, FzD - License Number Expiration Date
Name of CSL Holder
J List CSL Type(see below)
No.and Strut /�� C l ' a/ Type Description
�/,,�1////)�'�1/ U Unrestricted(Buildings u to 35,000 cu.ft.
7 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
b V I Insulation
Telephone Email address D Demolition
5.2 Regis eed H In r vementC�ontracto/ H /Jv$� tl t I
/e -w y" HIC Registration Number Expiration
Date
HIC Compa6L ame�gt�%,}II�Re ame
-No:and Stree / o`75-7 Email address
?7'(_.
City/ own Stag ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be compl ed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of a 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 � AoD
to act on my behalf,in all matters relative to w rk authorized by this building permit application.
Q4.
Print Owner's Name( lectronic Signature) Date
SECTION 71b: 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 accur, 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
mm .mass. og v/oca Information on the Construction Supervisor License can be found at www.mass,%zov/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"