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• The Commonwealth of Massachusatts
= Board of Building Regulations and Standards "" ' ` L -4"VVI
�
Massachusetts State Building Code, 780 CMR SALEM; 1011 ,12
Building Permit Application To Construct, Repair, Renovate Or Demoltsa
y One-or Tivo-Family Ihcelling
This Section For Official Use Only
Building Permit Number: Date Ap lied:
3
l 1l(
`--� Building Oficial(Print Name) Signature Date
SECTION 1: SITE INFORNIATION
1.1 Propeirty Address: 1.2 Assessors Map&Parcel Numbers
L t a 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: (bLG.L c,40,§5 ) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Lklunicipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
!`14S-PW,4q0 S(t. P t1/I , d
Name(Print) City,State,ZIT
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 Work': _
SECTION 4: ESTIldATED CONSTRUCTION COSTS
Item Estimated Costs: Official U Only
Labor and Materials)
1. Building $ 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 $
Suppression) Total All Fees: $
ChecCo
k No. ust: Cash Amount:
6. Total Project Cost: $ J6 7, (I� ❑ Paid in Full ❑Outstanding Balance Due:
a IL L- k--V -t--b � 13 I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Vl V.- rnh y1P L-U�' Z License -C ��] Eviration Date
Name of CS J VT Description
S1 • Sateopt,A44 1�70 U Unreshicted to 35,000 Cu.Ft
Ad Restricted 1&2 Family Dwelling
_ M Masomy Only
RC Residential Roofing Covering
-oda
�-7 -7 / WS Residential Window and Siding _
SF Residential Solid Fuel Burning fiance
Telephone D Residential Demolition
5.2 Home Improvement Contractor Registration(MC) ExpirationDate
— 6 2t�-J-AL2 9 , e--p- Registration
HIC Com y N e or HE Registrant Name�.
Address �-
Signature
Telephone
SECTION 6: ;WORKER?S COMPENSATION INSURANCE AFFIDAVIT(M.G:L.c.-152.§25C(6))
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance aflpavit may result in the denial of a building permit.
Signed affidavit attached? Yes No O
SECTION 7a: OWNER AUTHORIZATION.TO BE COMPLETED WHEN OWNETt'S AGENT:OR
_ CONTRACTOR APPLIES,FOR BUILDING PERMIT
I, 6 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. 6/1_/
Signature of Owner Date
SECTION 71i: - OWNER OR AUTHORIZED-AGENT DECLARATION
as Owner Owner or Authorized Agent,hereby declare that the statements
and information foregoi application are true ands accurate,to the best of my bowl ge an belief.
Signature of Owner or-A&hodzed 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 roperly licensed soli waste disposal facility as defined by MGL c111,§
150a. Zup„�(Lt Q
DEBRIS DISPOSAL LOCATION
SIGNA'T'URE 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(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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR
Regulations.