221 LORING AVENUE BPA 16-221 BASEMENT DOOR The Common%�ealth of Via;sachu;ett;
_.
,, Board Of Building Regulations and Standard; Fit ''C "YOF
Massachusetts State Building Code, 780 CMR SALEM
pLL�
Building Permit Application To Construct, Repair, RenoR isdlar?011
vate ei(sh5
t One-or Two-Family Dwelling-
-his Section For Official Use Only
Building Permit Number: Date ApO Lied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORN LTION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
og,'tj eAye11cy2...
1.Ia 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: (iNLG.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage'Disposal System; -
Public❑ Private❑ Zone: Outside Flood Zone? -
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Re rd:
L.,- 'Al I oy►a 6 I q7 b
Name(Print) City,State,ZIP
Qd I L e,e; G- Aye�l u ��- �-1
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�orl :
-PD G f,o ,P_k i V1 jo j2&e m e N
SECTION 4: ESTVNIATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ ( 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑ Total Project Cost' (Item 6)x m tp��� x
3. Plumbing $ 2. Other Fees: $ 0
4. Mechanical (HVAC) $ List: �p s
5. Mechanical (Fire
Suppression) $ Total All Fees: $
'�' �. 6D Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due:
2-17 1 mn,�N- p TO P�� A
SECTION 5: CONSTRUCTION SERVICES: -
5.1 Construction Supervisor License(CSL) License �,���-)—Z� Expiration Date
��Gl r ic 1. n��h U Z`f T Description
Name of� /V
/U U Unrestricted to 35,000 Cu_Ft.
1 J44 . Restricted 1&2 Family Dwelling
A r M Mas2pry Ont
RC Residential Roofia Covering
i (� WS Residential Window and Siding
2�— -7 ( 1 SF Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition r
5.2 Home Improvement Contractor Registration(HIC) Regiscation Date
tration �
HICCom yN eorHIC y e
Address J
Signature
7Y-7Lil - 0
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 a�No
may result in the denial of a building permit
Signed affidavit attached? Yes '
�. .... ,
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED RT�N OWNER'S AGENT:OR
CONTRACTOR APPLIES.FOR BUILDING PERMIT
I, as Owner of the subject property,
hereby authorize l ���'le V L CPS _to act on my behalf in all matters relevant to work
authorized by this building permit application.
Date
Signature of owner
SECTION 71: OWNER OR AUTHORIZED.AGENT DECLARATION
as Owner or Authorized Agent,hereby declare that the statements
and information fore .application are true ana curate,to the best of my knowl ge and lief.
- � 56
Signature of Owner orAftthonzed Agent (Signed under the pains and penalties of perjury) Dare
SECTIONS: DEBRLS 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 mi a roperly licensed soliwaste disposal facility as defined by MGL clil,§
150a. Zu sle,- ed— 6 C� J4, St IP-i-?,, 1k1,4 015 78
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(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.