0020 BEACH AVENUE-BPA-11-723 a The Commonwealth of MaSSaehUSCttS
Board of Building Regulations and Standards t2008
Massachusetts State Building Code, 780 CMR, 7ib edition
K
Building Permit Application"fo Construct, Repair, Renovate OeD'emolishja
One-or Two-P tiv Dwelling
This Secti n F r Official Use SAfy
Building Permit Number �, •D e App
Signature: / ���
B m ( /
uildingC missioner/Ins etorof Buildin, Date
SECTION :SITE INFORMATION
%rp :,AAdh esi 1 1.2 Assessors Map& Parcel Numbers
Iola Is this an accepted street?yes t/no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'? Munici al❑ On site dis osaf s stem ❑
Public❑ Private❑ Check if yes❑ F F y
SECTION 2: PROPERTY OWNERSHIP'
I.L Owner of cord:1
o�t ry S�r u �KIL
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Cl Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ AccessoryBidg. ❑ Number of Units_ Other Specify:
Brief Description of Proposed Work'
6
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building $ 7•A-O .00 I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Cost'(Item 6)x multiplier s
3. Plumbing S 2. Other Fees: S {� />
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5 Licensed Construction Supervisor(CSL) a/Z l r 7 (3 �oZ
n ..QO-LA ✓Ck t S License Number lis iratio Date
ttgn of l'SI.-elo er "V S�k WL
C List C5L Type Isee below)
. ddress Tvve Description
Il Unrestricted(tip to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
^Signature M %fasonry Only
RC Residential Rooting Coverin
I elephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5 9 g et H o Im
S wm ent Contractor(HIC) j
is id
3
IIICC�pa Name Registration Number
On � eorlll(U��rtrrt
o7O
ress
Esp' tion Date
Signature 'Lcicphone
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 .......... ❑ No...........❑
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 71b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, 4?ie 1 tc/d! r 5- ,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
be N
O.r,
ml Name
Signature of Ow er or Authorized Agent Dale'
(Signed under the pains and penalties ofperjury)
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(111C) Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115,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 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"