0011 VISTA AVENUE BPA-17-190 The Commonwealth of Massachusetts
r ry Board of Buildin- Regulations and Standards CITY OF
Massachusetts State Building Code 780 0 R SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Ttico-Fancily Lheelling
This Section For Official Use Only
Building Permit Number: Date A ied:
Building Official(Print Name)
Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
L I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zonin15
a 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[IZone:
if yes[] Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner`of Record:
Name(Print) City, State,ZIP
I 1 V'-S---Q -Ay� . `�7�'-pi's_ l 3 y
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': 11 5-�a `
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials) Official Use Only
1. Building $ )-6,) -,(-) C)7 1. Building Permit Fee:$ Indicate how fee is determined:
11 Standard City/Town Application Fee
2. Electrical $ ❑ Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S e,16)C)0 ❑ Paid in Full ❑Outstanding Balance Due:
�2� M Gk---0 TV C C�
r
SECTION 5: CONSTRUCTION SERVICES : .
5.1 ��C;;orn-struction Supervisor License(CSL)
A r K S-�rn)ka A ZC l�' Z� License}-(��_]� Expiration Date
Name of�^ -7
/!�l '� /U TU Unrestricted to 35,000 Cu-Descriptic
AddrrV� Restricted 1&2 Family Dwelling
M Masonry Only
i _ /
RC Residential Roofing Covering
q CY -7 q1 —O Y l�/ WS Residential Window and Siding
/ a 417 SF I Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition
5.2 Home Improvement Contractor Registration(HIC)
6;T/ ,L9 U r OY S Relstration Expiration Date
HIC Com y N e or HIC Registrant Name ` q-;o
Address
Signature
72
Telephone
SECTION 6:.-.WORKER?S COMPENSATIONINSURANCE AFFIDAVIT(M.G.L.c.-152.§25C(6)) .,-
Worker's
5C(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�OWNEWS AGENT-'OR '.
CONTRACTOR APPLIES.FOR BUILDING PERMIT
I, '✓lam M ✓� as Owner of the subject property,
hereby authorize V to act on my behalf in all matters relevant to work
authorized by this building permit application.
1ka
a r-()vr + `
Signature of Owner Date
SECTION 76: OWNER OR AUTHORIZED AGENT DECLARATION
I, r Z as Owner or Authorized Agent,hereby declare that the statements
and information fore i application are true ana accurate,to the best of my knowledge and belief.
-
Af
Signature of Owner or-Adthorized Agent (Signed under the pains and penalties of perjury) Dare
SECTION'S.;, 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 aroperly licensed soli waste disposal facility as defined by MGL c111,§
150a. Zup�.;�t a.�" 11 A)QAf �SA 2 h; A14 0/
DEBRIS DISPOSAL LOCATION 1
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 Constriction Supervisor Licensing(CSL)can be found in 780 CMR
Regulations.