B-17-371 - 0014 BEACH AVENUE - Building Permit 4 The Commonwealth of Massachusetts , (^ #rrp
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Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR SAL>JM :.,
TQI j MAY d Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish Y ev' ,S 4 b '
One-or Two-Family Dwelling
This Section For Official LTse Only r
Building Permit Number Date Apply
BWdmg Official(I'rmt Name) Signature Date
„(\ SECTION SITE INFORMATIQN .,77777.':
1 1. P opr4ly Add ss: 1.2 Assessors Map&Parcel Numbers
L la 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 Ley Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2'PROPERTX ONERSHIPi
`Owi�eriRecord: e,, I P 191 b
�Y � ..J'�. o` p 1
Name( 'nt) ;. r V CityState ZIP
No.and Street _ Telephone Email Address
7777
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief De cription of Proposed Work2: i
v • a
P
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs R
Item Official Use Only
Labor and Materials
1.Building $ 00 o A. Building Permit Fee $ Y Indicate how fee is determined:
2.Electrical $ D Standard City/Town Application Fee
C]TotAlTrolect Costa(I16th 6)x ifiultipHer x
3.Plumbing $ )q 000 2. Other Fees..$ r
4.Mechanical (HVAC) $ 2,0 000 List:.
5.Mechanical (Fire $ i
Suppression) Total All Fees:$
Check No Cheek Amount Cash_Amount:.
6.Total Project Cost: $ 1 000. p Paid.in pull I]Outstanding Balance Due.
C(J.fit_ B oc:,
Lm o v,�
SECTION 5: .CONSTRUCTION SERVICES
5.I Cunst uction Supervisor 'cease(CSL)
License Number Ex Vi t—io nf Date
Name 'CSL Holder List CSL'rype(see below)
Type' `. Description .
o.and Street U Unrestricted(Buildings Lip to 35,000 cu. 11.
R Restricted 1&2 Runily Dwelling
City/rmm,St te,ZIP �&I %4asonry
RC Rooting Coverin
INS Window and Siding
SF Solid Fuel Burning Appliances
�j (VIR �• I Insulation
Telephone Email ad&ess D I Demolition
Registered [tome Improvement Contractor(HIC) )—,�;51 ` a-j ),
!� HIC Registration Num er E.piruti Da
ill/C i Name or HIC istr�nt Name
n fG �,13p;V'� .'�
rAl. and Stre OI�)�/ P4 Email JJress
City/Town Stfite,ZIP Telephone
SECTION b:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.15Z.0 WOW. '
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Is§uanc of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED.WHEN—.-' :
OWNEWS AGENT Oil CONTRACTOR APPLIES'FOR BUILDING.P�RdII
I,as Owner of the subject property,hereby authorize + -
t9 act on my behalf,in all matters re alive to work authorized by this building permit appl' ation.
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17
Print Owner's Name(Electronic ature) a e
SECTION 7b:OWNEW 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 true and accurate to the best of my knowledge and understanding.
' LTIP �.
Print Owner's or Authorized Agent's Na ie(Electronic Signature) Date
NOTES:
I. An Owner who obtains a buildi g permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Imp ovement Contractor(HIC)Program);will nut have access to the arbitration
program or guaranty fund under INI.G.L.c. 142A.Other important information on the HIC Program can be found at
xvww.mass.gov:'oca Information on the Construction Supervisor License can be found at+www.mass.govhlns .
2. When substantial work is planned,provide the information below:
"total floor area(sq.R.) 1 (including garage,finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces ) Number of bedrooms
Number of bathrooms L Number of half/baths 0
Type of heating systems Number of decks/porches
'type of cooling system t.fc�eps,� Enclosed Open
3. "total Project Square Footage"may be substituted for"Total Project Cost"