10 BEACH AVE - BPA-11-296 ENCLOSE PORTION OF PORCH The Commonwealth of Massachusetts
Board ul'Building Regulu6uns and Standards CITY
\
C119
Massachusetts State Building Code, 780 CMR, 74'edition (IFSALEM
Revised Jmnnwy
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. :aAY
C A One-or Avu-Family Dwelling
�\ This Section For Official Use Only
Building Permit Num Date Applied: p2
Signature:
Hui mg ssioner/Inspector of Buildings this —�
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1 � rA enc t f'✓e-
I.I a Is this an accepted street?yes no v Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Ama(sq Il) Frontage(11)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone'
Check if es❑
Municipal 13 0,site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
XName IPrint) Address for Service:
El�ere ryl A� /trots YA,
SignatuTelephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check an that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) O 1 Alterations) ❑ Addition ❑
Demolition ❑ I Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OIRcId Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S C3 Standard Cily?own Application Fee
❑Total Project Cost'(Item 6)x multiplier x
). Plumbing S 2. Other Fen: S
4. Mechanical (UVAC) S List:
S. Mechanical (Fire S
Su ression Total All Fees. S
XCheck No. Check Amount: Cash Amount:
6. Total Protect Cost: S CO 0 OC 0 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervlsor(CSL) d4 20 q /
F77 G"rC V*i*t LL I.iceme7 Number 1:. pin n IYjlc
Name of CSl.- 11"IJer A I.ist CSL rypetseebelow)
/ �L gXtC f� A V F f Descri ion
/ :WJ Unrearicted u to 73.000 Cu.Ft.
'y L�� ,'1'Y• R Restricted 1&2 Famil 0%ellin
'\ tiigruw / M M Onf
RC Residential Roofing l'overin
felepltone WS Residential Window and Sidin
0(7g s7g 146 I SF Residential Solid Fuel Ru ina Appliance Installation
0 Residential Demolition
5.2 R�•���, Homelmprove atContractorC- /a-41�G
�
I IIC Company or f IIC RRegistration Number
egt t Name
j ;1o/ 7
Addre Q70 9-78 Lrspir stion Date
n Sigtmure T.lephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISI. / 2SCM)
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..........O No...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
signature of owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
F-
A as Owner or Authorized Agent hereby declare
he statements and information on the foregoing application arc true and accurate,to the best of my knowledge and
f.ane , /v
Signat re of0wner or Authors Agen1 Date -
Si under the sins and penalties of 'u
NOTES:
I. An Owner who on,
a building permit to do his/her own work, or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L.c. IJ2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I O.R6 and 110.14 mpectively.
? When substantial work is planned,provide the intormation below:
Total floors area(Sq. Ft.) (including garage, finished basemen✓attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of h3l0aths
Type of heating system Number of decks/porches
Type of cooling system Enclosed ()pen
). "Tidal Project Square Footage" maybe substituted for"Total Project Cost"
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