166 OCEAN AVE W - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR, 7`s edition ReOF S LEM J
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
'this F,
ffictlUOnqe or s
Building Permit,Num ri Daate Applied: ' ve
Signature:
-
g 3 O
B
uddmg Commissioner/"Inspector ofBmlding's .Date,
is SECTION 1: SITEINFORMATION ^_
1.1 Property Address: Au8 -w� 1.2 Assessors Map&Parcel Numbers
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.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone.Check if yes❑ P system Municipal❑ On site disposal stem ❑
-SECTION PROPERT„Y'OWNERSHIPt'`
2.1 Owner of Record:
.0
Am
\ Ad res for Service:
Signature - Telephone
SE TI z" allthat apply)
C . ON 3.DESCRIPTION OF PROPOSED WORK (check
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition . ❑ Accessory Bldg. ❑ Number of Units Other O-Specify:
Brief Description of Proposed Work':
C�
I
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offfcial.Use Only
Labor and Materials ^^
- 1.Building $ 1, Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ "❑Standard-Ciry/Tbwn Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2 Other Fees $
4.Mechanical (HVAC) $ List. .. a'
5.Mechanical (Fire
Suppression) $ Total All Fees $'^_
Check No Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid"iuFull ❑Outstanding Balance Due:
SECTIONS;, CONSCRUCTIONSERVICE$
5.1 Licensed Construction Supervisor(CSL) �—
Mi , ? e L License Number Expiration Date
Name of CSL-Holder qq List CSL Type(see below) (/
���PVLtIyUOc� ,�iU . (��� ;, ,
Address a T' ,. 'Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature /" M Masonry Only
!--7!':— "S`� 13 RC Residential Roofing Covering
Telephone WS- Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re istere Ho to I provement Contract(HIC) �Q „_u
_ ri;c.0 L-. C-
HIC Cot)Ipan Name or C Reg tj nt me Registration Number
Address 7n _ cl- � Q
4 / y G71_7q, EA3 Expiration Date
Signature T-eleephone :/
SECTION 6 WORKERS'COMPENSATION INSURANCE'AFFIDAVIT(M;q.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 13E,COMPLETE�1)WHEN;;
OWNER'S AGENT:OR= ONTRACTOR APPLIES'FOR BUILDING-PERMIT M
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative t work authorized by this bui ding pelt application.
/:.e yliU
i n lure of Owner - - Date
SECTION 7bi<OWNER':QR AUT-IIORIZEDrAGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
L 1 .
Print Name .�
14�/. �i -e.,C�eL_
Signature of Owner or Authorized Agent Date
Si ned under the vains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"