0005 FOREST AVENUE BPA-17-189 Z 37 SS
• The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building, Code 780 C1NIR SALEM
� Revised Llar?O!1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
f� One-or Two-Family Ihcelling
l This Section For Official Use Only
(� Building Permit Number: Date Ap ied:
1— OR og
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
6v 4-0 :-t L-a
1.1 a Is this an accepted street?yes no Nlap 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Nlunicipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rord:
-��Ck,VAr1 R/I Al 11- 0 l Y`7 Gk
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) W Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': s2 -j-cz!/ CLOVJ_VkVJ
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ Ll 0 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 7�` Ll ❑ Paid in Full ❑Outstanding Balance Due:
PA 2�1 k U";P 3
SECTION 5: CONSTRUCTION SERVICES.' :-
5.1 Construction Supervisor License(CSL)
A r�c n A Z�)i2 Z� License}—C���] 3�3 Expiration Date
Name of CIL - �y—7 T Description
N P l Umestricted to 35,000 Cn.Ft.
Ad Restricted 1&2 Family DwelLing
M MasonlY Only
RC Residential Roofing Covering
Sig-Tine
�� �i� � WS Residential Window and Siding
Q SF Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition
5.2 Home Improvement Contractor Registration(HIC) /
6 Registration Q Expiration Date t0 (O
HIC—Com yN (e orIRC R o� tN e�. �n
2' v[
Ad
Signature
7, -7�1I - 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 affi vit may result in the denial of a building permit.
Signed affidavit attached? Yes No O '
SECTION 7a:- OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERIS AGENT:OR
CONTRACTOR APPLIES.FOR BUILDING PERMIT
as Owner of the subject property,
hereby authorize FSI f—r=�(� �}t Ces to act on my behalf in all matters relevant to work
authorized by this building permit application.
. e c ovd -6t--� - I -?- l -I
Signature of Owner Date
SECTION 7.6: OWNER OR AUTHORIZED AGENT DECLARATION
I, - �Tll Y— Z as Owner or Authorized Agent,hereby declare that the statements
and information fore 3ingi application are true an_,d accurate,to the best of my knowledge and belief.
Signature of Owner orAdffiodzed Agent (Signed under the pains and penalties of perjury) Dare
SECTIONS: 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 soliwaste disposal facility as defined by MGL c111,§
1502. D� uwf,�t-
DEBRIS DISPOSAL LOCATION f
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 IRC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR
Regulations.