19 CLOVERDALE AVE - BUILDING PERMIT APP The Commonwealth of Nlassachusetts
CITY OF
Board of Building Regulations and Standards
SALELM
Massachusetts State Building Code, 780 CLMR dMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
Chis Sectton.FbrOfficial Use Only
Building Permit Number. . Date App d?
BuildiitgOfficial(Print.Name) '.'Signature - Date
SECTION 1:SITE INFORA&TION
1.1 pp erty Address A L2 Assessors Map& Parcel Numbers
�L e' dF ye-
1.1 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.O.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❑
SECTION 2:,PROPERTY OWNERSHIPL
2. wnert of Record: / �
Name(Print) City,State,ZIP
12 -- 6 4 -s-91 y
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTEvLaTED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only,
Labor and Materials
I. Building S 1 Building Permit Fee..$ Indicate how fee is determined:
�. Electricrl $ ❑ Standard;City/'Gown Application Fee
❑Total 0i63ect Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. M-ch:mical (1IV.\C) S List:
5. Mechanical (Fire $
Su ression) _ _ Total All Fees: $_
Check No. Check Amount: Cash :\uwunt
fi. 'Total Project Cost: SL''r ❑ Paid in Full ❑.Outstanding fial;ulce Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number 8.epiration Date
Name of CSL I!older
List CSL Type(see below)
No. and Street Type Description
U Unrestricted Duildin s up to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
Cityrrown,State, ZIP II Nlasonr
RC Roofing Covering
WS Windoav and Siding
SF Solid Fuel Burning Appliances
I Insulation
l'cle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or fIIC Registrant Name
No.and Street Email address
City/Town,State, ZIP Telephone
SECTION 6: WORKERS' CODIPENSATION 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 .......... ❑ 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 7h: 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
:ontaine application is true and accurate to best of my knowledge and understanding.
01
Print Owner's or Aut writcd Agcnt'e Nance(Electronic Signature) Date
NOTES:
I. :1n 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 aunt have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the EIIC Program can be found at
loww.nlass.�'uvioca Information on the Construction Supervisor License can be found at www.mass.auv dpv
2. When substantial work is planned,provide the information below:
Total floor area(sq. It.) (including garage, finished bnselnent u[tia, decks or porch)
(iroSi living area(sy. tl.) _ Habitable room count
Number of tinplates_-.—_-__--- Number ofbClrooms ,_------ --—_--
Nuntbcr of bathrooms ---- _-- Number of hall,baths -- — _
fepe of heating system - ---------- ----__-- Number of decks/ parches
peof cooling i}'<tana _----_---...-.—.-- Enclosed_ _ __ - Opcn
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