B-17-1005 - 0027 BARR STREET - Building Permit The Commonwealth of ivla„aehlu
�;; % Board of Building Regulations anci'Sb-��Pd "kl ' �' CITY OF
Massachusetts State Building Code 730 CivIR SALUM
Revised filar 2011
i ii
Buildir% Permit Application To Construct, Repairir,, enono vate r ernolil a
One-or Two-Family Ihvelling
This Section For Official Use Only
Building Permit Number- Date Ap ied:
Building Official(Print Name) Signature Date l"
SECTION l: SITE IrNFORiNtATION
1.1 Property Address:.
l 1.2 Assessors Map& Parcel Numbers 1.1a Is this an accepted street?.yes V1_no Llap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(t-------------
�j
1.5 Building Setbacks(ft)
Front Yard .:Side Yards
arils Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (�NLG.L c.40,§54) 1.7 Flood Zone.Information: 1.8 Sewage' posal System:
Public❑ Private❑ Zone: Outside Flood-Zone?
:_ -...:. Check if yes❑ -
'Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wneri of Record:
Name(Print) City,State,ZIP
No.and Street
13
�_�3Z—(aS°7
Telephone Email-Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(ch.eck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 11 Repairs(s) ❑ Alteration(s) Addition
Demolition ❑ Accessory Bldg. 11 Number of Units Other ❑ Specify:
Brief Description of Proposed Work: -` 0 ZZ
pm
ovfo WZ 0(Vl3
SECTION 4: EST,IMATED CONSTRUC.TION,-C..OSTS..-,
Item Estimated Costs;, Official Use Only
Labor and Materials) Y
1. Building $ �y 13 sg 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: . PIK,
5. Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount. Cash Amount:
ng Balance Due:
: .'
6. Total Project Cost: $ °`L 7� �5�- ❑,paid in Full ❑Outstandi
�'►'�;,.c ( 6 16
SECTION 5: 'CONSTRUCTION SERVICES.'
5.1 nnConstruction Supervisor License(CSL)
(m Li
t�l y icS�jh ha � � )�Z� censee}-a�'J-7 aa Expiration Date
Name of CSL II ^ G-7/i T Descd ion
1� ' l /C�1 1 l 0 U Unrestricted to 35,000 Cu_FQ
Ad WR
Restricted 1&2 Family Dwelling
M Masonry Only
RC Residential Roo Coverm
f 9 1 G (/J — -Z("} ] WS Residential Window and Siding
_
/ /J ~ - 1 I 4/y SF Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition
51 Home Improvement Contractor Registration(HIC)
A ?� I�r s Registration Expiration Date r0 6
HiC Com y N e or HIC Registrant Name
.Address -
Signature
` 7, -7Nl
Telephone
SECTION 6: WORKER'S COMPENSATION INSURANCE AFFIDAVIT(NLG L. c.-152. §25C(6)) -
.• .
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an ini;irance afFi vit may result in the denial of a building permit
Signed affidavit attached? Yes Nor 0
SECTION?ac' OWNER AUTHORIZATION.TO BE-CO MPLETEDWHEN+OWNER,SAGtNT-OR
CONTRACTOR APPLIES FOR BUFLDING PERMIT- =
as Owner of the subject property,
hereby authorize �P ie(3 l CPS to act on my behalf in all matters relevant to work
authorized by this building permit r.r application.
� -4 �q
Signature of Owner �` Date _
SECTION 71i: OWNER OR AUTHORIZED AGENT DECLARATION.
I, C - Z as Owner or Authorized Agent,hereby declare that the statements
and information fore application are true and d accurate,to the best of my knowledge 9d,belief.
17 r _ 1.I
_ _
Signahue of Owner or A&horized Agent (Signed under the pains and penalties of perjury) Daze
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 mi a roperly licensed soli waste disposal fGacility as defined by MGL clll,§
150a. ZuJ�4.AJ_ Jic-70iC-AA + ,SoL 2�, /11,4 O/ / 7c3
DEBRIS DISPOSAL LOCATION
SIGNATURE OF APPLICANT 45�7,�,Z'
NOTE
An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor(not register ed 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 CUR
Regulations.