15 CLOVERDALE AVE - BUILDING PERMIT APP cf-', 30�s3
Z3 RECE�V`Inup D CES
The Commonwealth of Massachusetts
r Board of Building Regulations and Standards CITY F
l\ / Massachusetts State Building Code, 780 CMR NIS MAY 13
Revised War 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pplied:
n Building Official(Print Name) Nignature Date
SECTION 1: SITE INFORMATION
1 1.1 Property Address: n �„I/1�/I 1.2 Assessors Map&Parcel Numbers
I� I.I a 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(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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner'of Re d: /y n�
Patricia Lenares (f� 6
Name(Print) �K n M r 4 i .State,Z[ )y
No.and Street �� clephone I Email Address
SE ON 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Constructio Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ S ecify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building $ VV I. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
to ❑Total Project Cost"(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
�) Check No. Check Amount: Cash Amount:
6.Total Project Cost: $I w 0 Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Con truction Snuperv' r License(CSL) (� /
Irf w, License Number Expira ion Dale
Nam�SL���Illolder p
List CSL Type(see below)
No.and r �(�,l�uJ W Type Description
U Unrestricted2 Family
(Buildings u el ing cu. HJ
�N R Restricted 1&2 Famil Dwelling
City/Town, ate,ZIPJ M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
u I Insulation
Telephone Email address D Demolition
5.2 Registered me Imp ov tt Contractor(HIC) DOW
I
UIHIC Registration Number Expiration Date
HIC Company N v HI is a t ame
No.and Street Email address
)61 � �
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 Issu ce 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Q��_a 5-12-2015
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER[ OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this app ication is th true accurate to e best of my knowledge and understanding.
y(A n &A -
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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. og v/oca Information on the Construction Supervisor License can be found at www.mass. og v/dos
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"may be substituted for"Total Project Cost"
EcolibriumSolar
"Layout
Skirt
c Coupling Note: If the total width of a continuous array exceeds 35 ft, break array to allow for thermal
O Clamp expansion and contraction. See Installation Guide for details.
Warning: PV Modules may need to be shifted with respect to roof trusses to comply with
0 Bonding Jumper maximum allowable overhang.
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