15 BEACH AVE - BPA-2010-169 ROOF Q
The Commonwealth of Massachusctis Town of
►, Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
` Building Permit Application To Construct, Repair, Renovate Or Demolish a tides'
One- or rtro-F jilt Dwelling
amoma
This Secti n or Official Use Onl
Building Permit Nu eer, Dal Applied:
Signature:
Budding Cornmtsstoner Spector of Hui[din Date
SECTION 1• Si E INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Ma Number Parcel Number
1.I a Is this an accepted street''yes_ no p
ti
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sq it) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Qfl
Rear YardRequired Provided Provided Required Provided1.6 Water Supply:(M.G.L c.40.f54) 1.7tion: 1.8 Sewage Dlaposal System:Zonod Zone? Municipal❑ On site disposal system ❑Public❑ Private❑ s❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 7nerIofRecord: / 5-
��v� �� 9r✓L
s-r lei cyars
Name(Print) Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
✓� h; r%n)(- 4 i frN e ✓
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlclal Use Only
Item Labor and Materials
I. Building Permit Fee: f Indicate how fee is determined:
1. Building f
❑Standard City/Town Application Fee
1. Electrical f ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) f List:
5 .Mechanical (Fire s Total All Fees: f
SU ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: f �q 60 7 ❑ Paid in Full ❑Outstanding Balance Due:
A,��� �� ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) d-8
y�
VR✓ • �' 3d_/1Jd1 License Number Expiration Date
N;tme ut'CSL- Ilplder
/ ,n=„�f� L am_ List CSL Type(,cc below) IJ
A rss= v T'pe Description
V� ir ). -D C9 a--� U Unrestricted u to 75,000 Cu. Ft.)
R Restricted 1&2 FamilyDwellin
Signet r M Masonry Only
RC Residential Roaring Covering
Telepho 7.p- S3 (_ 7 6 6-3 wS Residemtial Window and Siding
SF Residential Solid Fuel Bumm Appliance Installation
D Residential Demolition
5.2 Pegistered Home Improvement Contractor(HIC)
HIC Coq pparty Name J Registrant Name Registration Number
J D m e.9S>d
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6)) r
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan a of the building permit.
Signed Affidavit Attached? Yes .......... E5 No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I• 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
1• �RJ` �e ram-. ,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
PJ -d-'i-c0 J
Signature of Owner c#Authorized Agent Date
St ned under the'adins and penalties of perjury)
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 I IO.R6 and I IO.RS, respectively.
1. When substantial work is planned,provide the information below:
Total 11 rs 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"may he substituted for 'Total Project Cost"