7 BEACH AVE - BPA-16-1106 REDO LIVINGROOM r The Commonwealth of Massachusetts r�-FiXjV D
Board of Building Regulations andStandardsr' Fit�°F t 'SSE }GJTY OF
Massachusetts State Building Code, 780 CMR 'SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair,RenovatM ISEUil aA K) 0.2
One-or Two-Family Dwelling
This Section For Officio Use Only:,.-.. .,W° E1-1FN„,
Building Permit Number a . Date
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'—'' „ •^. , . . S .. DateBuilding Oficial(Print Name) ignau
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". . ....-,:SECTION I:SITE INFORMATION .-.1,A-E r. .
1.1 Pro a ddre 1.2 Assessors Map&Parcel Numbers
ve1Ave-
1.1 a
.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
C Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided RequiredProvided 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 2i;PROPERTY.OWNERSHIP.,t,11,4k .
2.1 AtCw�erto 4' f i L// 0(�L?�
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Name(Print) / � City,State,ZIP
-7 &Ad4 44"V4s 6X;Z
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED,WORKZ(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 ofPropppsed W k2:
RerotnF'(-(" u; Id;•u /lomat , .vacs rd� s urs �+ a. G✓.9f�
' ;SECTION 4: ESTIMATED CONSTRUCTION COSTS„ i. '? L
Estimated Costs: ,`
Item Official Use Only
Labor and Materials "
i. Building $ Itq 9O .1"',.Building Permit Fee $ Indicate how fee is determined:
❑Standard City/Town Application Fee .,
2. P.lectrical $ 1 � ;
❑Total Project Cos (Item 6)x multiplier ' x
3. Numbing $ 2 Other Fees $ ray
4. Mechanical (HVAC) $ List
t,
5.Mechanical (Fire r `
Suppression) $ Total All Fees $
Check No: Check Amount a Cash Amount F
6.Total Project Cost: $ K�l ❑Paid in Full '"-'s. ❑Outstanding Balance Due
mel 0U44el�c dr,,_ m [3M��t-t— - o G .c .
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SECTION 5i CONSTRUCTION SERVICES ,
5.1 Construction Supervisor License(CSL)
✓ah�t /�. GS-d COQ
License Number Exp raticfn Date
Name of CSL Holder
List CSL Type(see below) '
No17. a St eet b k ,Descnption 's fl
/,l/, / U Unrestricted(Buildings u to 35 000 cu.ftJ
y�� r G l �4 ��� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP ' M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2R,�/i� stered/Home improvement Contractor(HIC) 16
/G)y_.?
//
1�6 ,,.AP �ntLs ,ge 6 3l- HIC Registration Number Expir^a"on Date
IT=j�' orIjC Re tram Name
No.�/td 5 ee4 a(4, 0 �����y.ii{ Email addr
Cit /Town, State,ZIP dP Telephone
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1111!1 .'SECTION6.WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) y-
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
ru=H u OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r"=
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I,as Owner of the subject property,hereby authorize V—,4, Te �/YtiZt��
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 7b 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
contained in this application is c nd accurate to the est of my knowledge and understanding.
TdAjq W. %4Wte
Print Owner's or Authorigent's Nam (Elec onic Signature) ate
;NOTES: s t
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.gov/dps
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"maybe substituted for"Total Project Cost"