0001 BOW STREET BPA-17-188 G 355
The CommomNealth of Nlassachusetts
-,� Board of Building Regulations and Standards CITY OF
1.
SALEM
y ,,, o, 'Massachusetts State Building Code, 780 CNIR
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
® One-or Two-Family Ihcelling
This Section For Official Use Only
(' Building Permit Number: Date Appy
I —
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORNLXTION
1.1 Pro erty Address: 1.2 Assessors Ntap& Parcel Numbers
l.la Is this an accepted street?yes no ivlap 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:
Zone: _ Outside Flood Zone?
Public❑ Private 13Zone:
if yes[] Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City, State.ZIP
16 o� .5 1 -7�—L09-lY `(�
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 13Alteration(s) Addition [3Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': /n .S `ct c,.,La_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ —� L1 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ s
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $-7 o+3( 3 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES,` -
5.1 Construction Supervisor License(CSL)
(1 Vl r�c S�Q�f e A �L)V Z'� Licenser_}—C���]�j Expiration Date
Name of CS /V T Description
U Unrestricted to 35,000 Cu.Ft.
Ad k Restricted 1&2 Family Dwelling
M Masonry Only
i RCResidential Roofing Covering
G� -7 q 1 —O q 1�/ WS Residential Window and Siding
/J I 41`� SF Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition
51 Home Improvement Contractor Registration(BE[C)
;t , e 1z C-P- s Registration Expiration Date 6 �v
HIC—Com y N a or H[C t Name�. y
Address t
Signature
7 -7Nl - ogct� .
Telephone
SECTION 6: WORKER'S COMPENSATIONINSURANCE.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 15Lzvit may result in the denial of a building permit
Signed affidavit attached? Yes No Q
SECTION 7a;':'OWNER AUTHORIZATION TO BE COMPLETEDWHEN OWNER'S AGENT:OR '.
CONTRACTOR APPLIES.FOR BUILDING PERMIT
as Owner of the subject property,
hereby authorize S�/2 V L cis to act on my behalf in all matters relevant to work
authorized by this building permit application.
`
Signature of Owner Date
SECTION 71i: OWNER OR AUTHORIZED AGENT DECLARATION :y
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.
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 roperly lic�e�nsed soli¢waste disposal facility as defined by MGL c111,§
150a. Gt,`f" �16�o 6- k cJ , Sjat rC lq,4 0/ !70
DEBRIS DISPOSAL LOCATION r
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.