37 BEAVER STREET BPA 17-115 q2 3
The Common�yealth of Massachusetts
Board of Buildin ..o [g Regulations and Standards -'' OF
Massachusetts State Building Code, 780 CMR 23 P SALEM
1k,1 FE Revised Har 2011
Building Permit Application To Construct, Repair, Renovate Or emolish a
One-or Ttico-Family Lheelling
This Section For Official e Only
Building Permit Number: Date plied:
iBuilding Official(Print Name) Signature Date
SECTION 1: SITE INFORIVL4TION
1.1 Pro erty Address- , 1.2 Assessors Map& Parcel Numbers
I.la 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: (M.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 Record:
_
w, r c 4.t4-P 0.( r►n 01.4 U t 7 Z U
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 11Owner-Occupied ❑ Repairs(s) 13Alteration(s) ;; Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units
Other ❑ Specify:
Brief Description of Proposed Worlc: ' 1,d
L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
L Building $ U 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: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ l 3�' L ❑ Paid in Full ❑Outstanding Balance Due:
M�k L_t� 1-0 c-A C, z( -Z-'J
SECTION 5- CONSTRUCTION SERVICES -
5.1 ��C;;onstruction Supervisor License(CSL)
Expiration Date
NameofCSL A) I y n T Descrion
, !�v U Unrestricted to 35,000 Cu.Ft
Ad Restricted 1&2 Family Dwelling
M Masonry Only
RC Residential Roofing Covering
1 WS Residential Window and Siding _
/ 0 �/I SF Residetial Solid Fuel Burning Appliance
Telephone D Residential Demolition
5.2 Home Improvement Contractor Registration(HIC)
_q t1 �e-9 1/ C-P S �B��on Eviration Date �0 6
HIC Com y N e or HIC Registrant Name 5 ` �
Adax6s
Signature
Telephone
SECTION 6:--r WORKERS 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 affi vit may result in the denial of a building permit
Signed affidavit attached? Yes No D
SECTION 7a' OWNER AUTHORIZATION.TO BE COMPLETED WHEN OWNER'S AGENT:OR `..
CONTRACTOR APPLIES.FOR BUILDING PERMIT
I ,,as Owner of the subject property,
hereby authorize �(�f2 l)l to act on my behalf in all matters relevant to work
authorized by this building permit application.
L, C()V +
Signature of Owner Date
SECTION 7b: OWNER OR AUTHORIZED-AGENT DECLARATION
as Owner or Authorized Agent,hereby declare that the statements
and informationfore i application are true an-d accurate,to the best of my knowledge and belief.
xu
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.properly licensed soliii waste disposal facility as defined by MGL c111,§
150a. �u � ed- I/CA)06k6 07t, SaL eh,/11.4 L) 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(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.