1 CARROLLTON STREET The Commonwealth of Massachusetts ,. i,.. ` �E ,
k Board of Building Regulations and Standards `" " `CITY OF
Massachusetts State Building Code, 730 CMR SALEM
2011 FEB 2 3 e2�e3kar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
w` One-or Two-Family Dwelling
( This Section For Official Use Only
Building Permit Number: Date pplied:
t
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORNLATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1 C ci ✓r c t NZ,>i
L l 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: (M.G.L c.40,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owrser'of Record:
:2L-R-, )cc V-- M d 3
Name(Print) City,State,ZIP
3 CGia✓ '7-78—YF::;k -
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': t C
V � ./' (�lam' V'�/1.`.✓r/ 1�.) ' /l C) .ice%J
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) 3'
1. Building $ f 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: $
6. Total Proect Cost: $ I Check No. Check Amount: Cash Amount:
j ❑ Paid in Full ❑Outstanding Balance Due:
Y�Ai �L—r� T-0 L C, 2�2�
SECTION 5- CONSTRUCTION SERVICES.'
5.1 Construction Supervisor License(CSL) License�`C�� Expiration Date
Name f� KRC Description
AN �—r Q 1 � 70Unrestricted to 35,000 CL.FQ
Ad s Restricted 1&2 Family Dwelling
Mas Only
Residential Roofm Covering
iWS Residential Window and Siding
�� y/ l/�� SF Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition
5.2 Home Improvement Contractor Registration(MC) RegistrationDate
� � 6
HIC Com y N e or HIC Registrant Name
Address
Signature
Telephone
SECTION 6:-.WORKER'S WORKER?S.COWENSATIONINSURANCE-AFFIDAVIT(MGL.c,452.§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 O
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHER'
N OWNES AGENT.OR
CONTRACTOR APPLIES.FOR BUILDING PERMIT
I, as Owner of the subject property,
hereby authorize ��' V l Cel to act on my behalf in all matters relevant to work
authorized
�\byy/this building permit application.
Signature of Owner -
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
I, , Y Z as Owner or Authorized Agent,hereby declare that the statements
and information fore i application are true a d accurate,to the best of my knowledge and belief.
r
Signature of owner or A or zed—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 soliwaste disposal facility as defined by MGL c111,§
150a. Zu It a,�- �lsn�o616 Sa eh,lkl.4 0/ / 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 MC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR
Regulations.