163 OCEAN AVE W - BUILDING INSPECTION Q\`? The Commonwealth of Massachusetts S
�• Board of Building Regulations and Standards ALCrry
OF
Building Code, 730 CMR dMar
Massachusetts State
Ravised bloc 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This SectonFordfficial Ujj Onl
Building Permit Number Date Ap to t;.
? .. e6 31%
Buiidtng Official(Pont Name) �Stgnatu;a Date
SECTION I:SITE INFORAIATIO(Y. .''.`
1, roperty Address: 1.2 Assessors Map&Parcel Numbers
i
1.l 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 T Provided
1.6 Water Supply:(M:G.L o.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❑
SECTIONZ:. PROP.ERTB'O}VNERSHIPL
2 Owner'of Record:
r l9eY 7- .-
Name(Print) City,State,ZIP -
9 t,7 mAT"61,L.t,6 A4_. SDI Foal k? r—kS 7—35'£ L/
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF. PROPOSEII WORK°'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : PJ
SECTION 4: ESTUNIATED CONSTRUCTION COSTS"
Estimated Costs:
Item Off cJai Use Only.. ,
(Labor and ivlaterials �
1. Building S '1b vO , A. Building Permit Fee:S Indicate how fee is determined:
❑Standaid.CityfiownApplication Fee.
3. Electric;d $ ❑'rotalPedJect Cost](Item.6)xmultiplier x
3. Plumbing S 2. OtherFee4:'S
I. M-chanical (IIVAQ S List:
i. Mxhanical (Fire S 'l'otal Ml Fees:.S -
5n � cession) -
- - Check No. _Check Amututt: Cash Amount:.
1'nrnl Pro
ject Oust: 3 f 0 Paid in Pull 0 Outstanding Dol:utcc I)uo:
—a
SEcrION 5: CO:Ns'l-RUCTION SERVICES
5.1 Construelioo Supervisor License(CSL) —
License Number Expiration Date
Name of CSL I lolder
List CSL'iype(see below)- 4
No. and Street Type I Description
U Unrestricted(Buildings up to 35,000 cu. tt.
ted 1&2 FamilyDwellin
City/rown,State,ZIP r
Coverin
PWDoemolition
w and Sidin
uel Burning Appliances
on
1'ele hone Email address tion
5.2 Registered Home Improvement Contractor(IIIC)
FIIC Registration Number Expiration Date
I IIC Company Name or lIIC Registrant Name
No.and Street Email address
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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........13 No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
701ner 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: OWNEW OR AUTfIORIZED'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.
_ — 6 - 3 -ta
Print wner's r A turize :\;ent's Name(Electronic Signature) Date
NOTES:
1. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program),will t have access to the arbitration
program or guaranty Cund under M.G.L. c. 142A. other important information on the HIC Program can be found at
wwvv m:us.¢uv%oca Information on the Construction Supervisor License can be round at
2. When substantial work is planned,provide the information below:
Tote tloorarea(sy. It.) —(including garage, finished basemenVattics,decks or porch)
t mmi livigy area(sq. It.) f fabitable room count _
Numberorliraplaccs_.--------- Number ofbcdronms
Number ofbathrouins Numberofhaltbaths -_----- —
1'vpc or boating iyvtcm . .. -- -._—.- Number of deck.,'porches
I)Ile ofcoolin" iyaem _._-- _----- ._-_-- F:ucloscd- -- - _ ( )Pell _------_— .-. -
1. I nr11 I'nq.�:t 5yu.uo may he inbinnitr,l t;.r"'I -t.d IIInicct Co it"
•; -/7", C I i OF &.UL lY� LYli���ikCL1 UtJE 1 1 S
7 f
t4 Bt;ILONG DEP.IRTSL&NT
110 WASHNGTOY STREET, 3"FLOOit
•, ` `; ItL (978) 145-9595
FAX(978) 740-93-14
Nckyo'm I1�tomuST.PIE7 z
DmECTOR OF PLOLIC PROPERTY/SLILDLNG CONWISSIONER
Construction Debris Disposal Affidavit
(required for all demalition and renovation work)
fn accordance with the sixth edition of the State Building Code, 780 Ch1R section 111.5
Debris, and the provisions of tbiCL e 40, 3 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be dispose I of n properly licensed waste disposal facility as defined by tNI'M e
l 11, S 150A.
The debris will be transported by:
(nano:uFhaulor)
The tlebris will be disposed of in
(AAIJ, � _
(name of facility)
13 LVUPuw ST
(addres.t of r:Kility)
,iguan c of limit applicant