63 OCEAN AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
r•'°a w: Board of Baildin_Regulations and Standards OF
t s� Massachusetts State Buildine Code., 780 CNtR SA E\9
fevised_ 4 r 2011
j Building Permit.Application To Constucl, Repair, Renovate Or Demolish a
One-or Two-Family Duelling
- This Section For OBicial Use Only
Buildine.Permit Number: Date Applied: _
� I
[3ud�ing OlTiaul(Print Name! Sigma It , Date
SECTION 1: SITE INFOR T'ION
1.1 Prn ert.v Address: 1.2 Assessors Map S Parcel Numbers
�C_ea_tn��.Sa�Ca_�_/rf'Lf}O/9ZO_ _
1.1 a I:(his an accepied street'?yes — do Map Number Parcel Number
1.3 Zoning Information: -- lA Property Dimensions:
Zoning District Proposed Usc Lot Area(sq ft) Frontage 1 ft)
1.5 Building Setbacks(ft)
4 Front Yard Side Yards Rear Yard
Required Proridul Required Provided Required Provided
I
1.6 Water Supple: (M.G.L e.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private Cl Zone: _ Outside Flood Zone°
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY ONVNERSHIPt
2.1 Owners of Record:
_emu r i
Naunc(Print) Citv.Stave.ZIP
_G3 OCP.w_A t o q78-52y- 0s7 y
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED \PORK'(check all that apply)
Neer Construction ❑ Existing* Buildine❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ t
Demolition ❑ Accessory BldL,.❑ Number of Units Other A Specify:✓ $a"
Brie!Description of Proposed Work':�j./-1
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only t
(Labor and Materials) k
1 Building S /0t eon I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S Z q•�u °'• ❑ Standard City/Town.Application Fee
❑"rotal Project Cost}(Item 6)x multiplier ,x
3. Plmnbing S 2. Other Fees: S
4. Mechanical (HVAC) S Lis(
5.Mechanical (Fire VVV
Suppression) S Total All Fees: S
6. Total Project Cost: S
Check No. Check Amoune Cash Amount
4t7.�J :
��
U ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction etion Supervisor License
icense(CSL) 3 ���d //� Zvi
`/, ✓, S�i ! �` _ License Number 0 Expiration Date
Name of"CSL I lolder
/ List CSLType(see below)_
' \b.anti Street --.—_ INPe Description .
A� M Unrestricted(Buildings u to 35.000 cu.III I
-- __—�—/ _ / 2 Restricted 1&2 Family Dwelling
Cite-?oten.State.ZIP M Masonry ,
RC Roofing Covering
- — WS Window and Siding
Solid Fuel Burning Appliances
7 O O Lbv I Insulalinn-
Telc hone Email address U 1 Demolition 5.2 Registered Home Improvement Contractor(HIC) 2/�12 a G-Id, Zj11y
J, �� ��I •`" I IIC Regisinuiiaon Numbcr Expiration Dais
I IIC Comport 'Nm1°
nc rHIC Registrant.'an e
✓Jst,/ Caste.
No.and Socci wI Email address
Citv`fown-State.LIP Q/ Telephone
SECTION fi: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(iNI.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 Allidavit Auaehed7 Yes .......... No........... ❑
SEC"rION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNUT
L 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 Siena are) T Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties ofperjury that all of the information
Conn ined in this a a oo iIIrne and accurate to the best of my knowledge and understanding.
I iut Owners or Authorized Agent s Name(Electronic Signature) Dale
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 Ibund at
u wtv.mass.aov'oca Infornmlion on the Construction Supervisor License can be found at www.mass. o
2. When substantial work is planned.provide the information below:
Total Iloor area(sq. III.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of f ii eplaces Number of bedrooms
Number of bathrooms Number of half/baths
"type o(hruing system_ Number of clocks/porches
Type of cooling system Enclosed Open
3. "Toad Project Square Footage"may be substituted for"Total Project Cost'
. CITY OF S.ULE:NI, Mass-kCHUSETTS
Bu LDING DEPAR•I1iEvT
• 120 W?\SHINGTON STREET,3'n FLOOR
ayj TEL (978) 745-9595
FA_r(978)740-98"
KI,\lBERi F_Y DRISCOL
MAYOR T�toslAs ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (BusinssotganizatioNlndividuaq: ✓- �' J�f �t/G
Address, /S�- _r& fwsL% 12,0.
City/State/Zip: CAJ? L(S(� ln4I [hone !f:at 7V/
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
nployees(full and/or part-time).* have hired the sub-contractors
2. 1 am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers'comp.insurance. 9, ❑ Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its
officers have exercised their 10.❑ Electrical repairs or additions
required.]
3.❑ i am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees.[No workers' 13.0Other S*d4111 11144"S
comp.insurance required.]
•Any applicant that chucks box BI most also fill out the section below showing their workers'compenwion policy information. -
t l hx+wowners who submit this affidavit indicating they me doing all work and then hire outside contractors must submit a new affidavit imhcadng such •.
-Comm".chat ch ck this box must anached an additional ahmi showing the name of the sub-contractors and their workns'comp•policy infomation.
l am an employer that is providing workers'compensation Insurance for my employees. Below Is the polity and Job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date.
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the polity number and expiration date).
Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certifyV�7> and penahfes of perjury that the information provided above IssL true and tarred
at Ire• Date: ifJ-
Phone
-
Official use only. Do not write in this area,to he completed by city or town officiaL _
City or Town: Permit/License#
Issuing Authority(circle one):
1.Beard of Health 2.Building Department 3.Citytfown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: _ Phone#:
CITY OF S�U.F.N1, TUNSSACHUSETTS
• BUII.DLNG DEPARTMENT
120 WASHLIIGTON STREET. Yo FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KjxjBER FY DRISCOLL
;MAYOR TH IA OAS Sr.PrERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDIING CONINIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
�Afi<� Gas ,&t/C' r
(name of facility)
J , 5W�A? S: .4aQ✓1W-
(address of facility) /
ature of permit applicant
date
Jcbrivil::lx: