15 BEACH AVE - BPA-2010-174 KITCHEN & BATH RENO. r ,
Q The Commonwealth of Massachusetts Town of
►—, Board of Building Regulations and Standards
Massachusetts State Building Code. 780 CMR. T"edition Building Dept
` Building Permit Application To Construct. Repair. Renovate Or Demolish a
tkvomwkwa
/v One- or Ttca-Fumily Dtrrffing
This Section For Official Use Onl
Z - Building Perini( Numhe . Date Applied: 3
Signature: rf/�ri�,rST
Buddin ommtssmnerl Inspector of Buildings Date
SECTION 1: SITE INFORMATION
L1 Property Address: Au— 1.2 Assessors Map& Parcel Numbers
Ma Number Parcel Number
I.la Is this an accepted street?yes no p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(fit)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rem Yard
Required Provided equirtid Provided Required Provided
1.6 Water Supply:(M.U.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Public Private❑ Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: /S /3 Lsy}c-if r l P O Ilk
Name(Print)/) ,, // Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Constructiori Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief DescJf tion o(Propos5yd Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building f 6 [/G •�" 1. Building Permit Fee: f Indicate now fee is determined:
❑Standard City/Town Application Fee
2. Electrical S -7 Sh, rN ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing S s6Zrd,r" 2. Other Fees: S
4. Mechanical (HVAC) S ,v/A Lisr. _
S .Mechanical (Fire -
- f Total All Fees: f
Suppression)
Check No. _Check Amount: Cash Amount:_
6, Total Project Cost: S /it 7S—e, ❑ Paid in Full O Outstanding Balance Due:
J
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N;(mc of CSL Helder List CSL Type ype(,cc below)
Address [VSFReside
Descn bon
tnetcd u to JS,000 Ca Ft.)
Signature cted I&2 Fomd Dwellin
Only
ntial Roofin Coverin
Telephone nt..] M.M.and Sidra
ntul Solid Fuel Bumin A liance Installanon
ntial Demolition
kaffidavit
egistered Home Improvement Contractor(HIC)
ompany Name or HIC Registrant Name Registration Number
ss
Expiration Date
ure Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(6))
rs Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
fidavit will result in the denial of the issuance of the building permit.
AITIJavit AttacheJ? Yes .......... O No........... O
ION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
R'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
e to act on my behalf,in all matters
to work authorized by this building permit application.
Signature of Owner Date
(� a SECTIO`N/7b:OWNERt OR AUTHORIZED AGENT DECLARATION
1, ILu SS -,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
g 3 r/o
Signatum of Owner or Authorized Agent Date '
(Signed under the pains and penalties of peru
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 W 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 110.116 and 110.R5, 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 halfbaths
Type of heating system Number ofdecksi porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may he suhsbtuted for 'Total Project Cost"