BPA-17-36 ROOFING The Commonwealth of Massachusetts_
Board of Building Regulations and Standards
SALEM
i Massachusetts State Building Code, 730 C1IR ,(
2011 A
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Officia se Only
Building Permit Number: Date /pptied:
low
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORNLATION
1.1 PropeAddress: 1.2 Assessors Nlap& Parcel Numbers
93 %A&SALIJ S ree+,
1.1a 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: (b[.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
25
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re rd:
rKANK ADIJO st9de6
Name(Print) City, State.ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'"(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': .
�eS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official U e Only
Labor and Materials)
t. Building $ 3 0 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
TT61
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES.:
5.1 ��Construction Supervisor License(CSL)
Zr))C-2_ I icense�}—( Expiration Date
Name of mT / G�70 rt T Description
li Q 1 /`1 � ! U Unrestricted to 35,000 Cu Ft
Ad s --R Restricted 1&2 Family Dwelling
M Masonry Only
i
RC Residential Roofing Covering
C� �j gaaYare q' —OqA M/ WS Residential Window and Siding
�J / `� SF Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition
5.2 Home Improvement Contractor Registration egistration(MC)6H —� 1Zt S Registration Expiration Date Ip
MC com y N e or HIC Registrant Name r—.
Address J
Signature
Telephone
SECTION 6:-:WORKER'S CON PENSATIONINSURANCKAFFIDAVIT(M G:L.!.-152.§25C(6))
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affi Vlt may result in the denial of a building permit.
Signed affidavit attached? Yes No 0
SECTION 7a 'OWNERAUTHOR17ATION TO BE'COMPLETED WHEN OWNER'S AGE NT.OR _
CONTRACTOR APPLIES.FOR BUILDING PERMIT. : _
as Owner of the subject property,
hereby authorizeCes to act on my behalf in all matters relevant to work
authorized by this building permit application.
"s-Ira 1'7
Signature of Owner Date
SECTION r7b: OWNER OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent,hereby declare that the statements
and information foregoi application are true!d-accurate,to the best of my know)edgepnd belief.
Signature of Owner or-Adthorized Agent (Signed under the pains and penalties of perjury) Date
SECTION 8: . DEBRIS DISPOSAL
All dumpsters of six(6)cubic yards or more are required to have a permit from the Marblehead Fire department:call 781-639-3428.
In accordance with the provisions of 780 CMR and MGL c40,§54 a condition of issuance of this building permit is that debris
resulting from any work performed shall be disposed of in a.Properly licensed soli waste disposal facility as defined by MGL c111,§
150a. �U L a,�' �lS1UO E- c SoL e i),11'IA 01 70
DEBRIS DISPOSAL LOCATION
SIGNATURE OF APPLICANT
.NOTE .
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 PC)Program)will not have access to the arbitration program or guaranty fund under M.G.L.
c. 142A.Other important information on the MC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR
Regulations.