BP APP 17-62 The Commonwealth of tMassachusetts
q; ` Board of Building Regulations and Standards :. ` ' mom .
�I SALEM
Massachusetts State Building Code, 730 CMR
f 2 x 'se*t.�ryo11
Building Permit Application To Construct, Repair, Renovate Or Demolts a
One-or Teco-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Ap lied:
i
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORTNIATION
1.1 Prop�e�ty Address: 1.2 Assessors Map& Parcel Numbers
;��� � 4 U c i (
1.1a Is this an accepted street?yes no ivlap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(tt)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (NLG.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Municipal if yes❑ unicipal 13On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�h�4 ,`JahuoviU k148kwA 10 SL (O nil . MA 0l q`fin
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 o op ed Work2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official UM Only
Labor and Materials)
1. Building $ 1. Building Permit Fee:S Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire 66$
Suppression) Total All Fees: $ Ilk
Check No. C ount: Cash Amount:
6. Total Project Cost: $ F6 7. (JU ❑ Paid in Full ❑Outstanding Balance Due:
r0 A'L L_EV 'C-b A t 13 1
SECTION 5: CONSTRUCTION SERVICES, :-
5.1 �C;onstruction Supervisor License(CSL)
( AV I(SID19Yl{� License?—C � Expiration Date
Name of CS T Description,
o -Saleilkt, 7U U Unrestricted to 35,000 Cu-Ft
Add?pV
y�lRestricted 1&2 Family Dwelling
M Masonry Only
i �/
RC Residential RoofingCovering
1 ' —D-q��/ WS Residential Window and Siding _
`)� SF I Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition
SZ Home 'in
y R� OII
ent Contractor Registration(HIC)
--�J �e ('� S V-1 L1--- iration Date (D
HIC Com y N e R
or BIC Egistrant dame�..
Address
5igoature
7�1
`� 7 - � - 0 � .
Telephone
SECTION 6:--:WORKER?S COMPENS knON.INSURANCE'AFFIDAVIT(M.G_L.c7-152.§25C(6))
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affi vit may result in the denial of a building permit
Signed affidavit attached? Yes No 1
SECTION 7a `: OWNER AUTHORIZATION TO BE'COMPLETED WHEN OWNER'S AGENT
CONTRACTOR APPLIES.FOR BUILDING PERMIT
as Owner of the subject property,
hereby authorize V to act on my behalf in all matters relevant to work
authorized by this building permit application
`'Su cw�-� " � b611-1
Signature of Owner Date
SECTION rr7li: OWNER OR AUTHORIZED AGENT DECLARATION
Zo Z24 as Owner or Authorized Agent,hereby declare that the statements
and informationforegoi application are true a a accurate,to the best of my knowl ge an belief.
.b II
Signature of Owner or-A orized Agent (Signed under the pains and penalties of perjury) Dare
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,�jroperly licensed solid waste disposal facility as defined by MGL clll,§
150a. u1 Sade h,/t1,4
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 HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR
Regulations.