23 BEACH AVE - BPA-15-913 ENLARGE BATH The Commonwealth of Massachusetts
W
Board of Building Regulations and Standards RECEIVED CITY OF
n Massachusetts State Building Code,78CTIONAL SERVICESRevised
A aM2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a O 1
One-or Two-Family Dwelling 1015 AUG 21 A
This Section For Official Use Only
I Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
(((� SECTION 1:SITE INFORMATION
1.1 My g ress: 1.2 Assessors Map&Parcel Numbers
'ers' 4u ,
_ Lla 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIPt
2.1 Ow t of Rgcerd• < J ,d
��5�/ r C J/t GJ
Name(Print City,Sty
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction❑ Existing Buildingx Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s)XIAddition ❑
Demolition ❑ I Accessory Bldg.Cl Number of Units_ Other ❑ Specify:
Brief Description of ProposedWorkz: TUilg71
SECTION 4:ESTIMATED CONSTRUCTION COSTS U
Item Estimated Costs: Official Use Only
(Lfbor and Materials
1.Building 60 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost"(Item 6)x multiplier x
3.Plumbing 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Su $ Total All Fees:$
Suppression)
Check No._Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
tAKrJ
SECTION 5. CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
c�/ !7 L
t_J ) ��� (JC,�j License Number Expiration Date
Name�Df7�CSL ]de� bbbQ _ I� A List CSL Type(see below)
4RC
No.and Street pescription Unrestricted Bui mil s u to ing 1 cu.ft.Restricted 1&2Fami] DwellinCi /Town, tate,ZIP Masonry
Roof= Coverin Window and Sidin/� 4�j�_ ((yy���� p/ �o (�� Solid Fuel Burning Appliances
( / ` �G�� /�C /'/wl✓C(kXInsulation
Tele hone Email address Demolition
5.2 Rueter d Home Improvement Contractor(MC) ._._,/
1i 1�7,, , I�U�y�c/' ' '�1 a_ti&N(um�ber Expiration Date /
HIC Com an- at o A f t d (Ll� l l)�Y� M�T�{U�L� a-t�6IW�� (��J
�d
N� d SX � Email addressa� O/S6D 61' 7 �iZ-
�C State,ZIFI Telephone
SECTION 6.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
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 .........A' No...........❑
SECTION Tat OWNER AUTHORIZATION TO 13E COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR'DUILDING 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7bt.OWNER` OR AUTHORIZED AGENT DECLARATION
By entering my name ow,I r by attest under the pains and penalties of perjury that all of the information
containe n is app ' do i e and accurate to the best of my knowledge and understanding.
� Z7- /bL
Print Owne s or Auth ' Agent's N (Electronic Signature) Date
NOTES:
1. 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
wtivw.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. ovg /dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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 be substituted for"Total Project Cost"