B-17-660 - 0010 BENTLEY STREET - Building Permit The Commonwealth of Nlassachtsetts
�; ' Board of Building Regulations and Standards . CITY OF
t `ems ,SEb1
Massachusettsi; assachusetts State Building Code, 780 CNIRr Q
t . 7Zevise'd Kfar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a f
® One-or Two-Fancily Dwelling 01.1 ja I A
J. This Section For Official Use Only
p Building Permit Number = Date ied:
-
Building Official(Print Name) Signature Date
—' SECTION 1: SITE INFORKA.TION
1.1Property Address:. 1.2 Assessors Map&Parcel Numbers
1.1 aa0Iss this an accept�t?yes ✓ no iv[ap Number Parcel Number
1.3 Zoning Information:
1.4 s Property Dimensions:
P
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❑ Municipal❑ On site disposal system ❑
Check'jfyes❑ .
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record
Cad\�e� Oe�ea��i a.\eNn I dCq-7
Name(Print) City,State,ZIP
W ZeLk�Qm SVree�_ 5og_S 43-9O8(Q C044em. kk(,-s`
No. and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 0 Alteration(s) Addition 0
Demolition ❑ Accessory Bldg � Number of Units Other ❑ Specify:
Brief Description of Ppo osed Work: D 3C.,�J B( y� ®F Jo
SECTION 4: ESTIMATED CONSTRUCTION,COSTS.._
Item Estimated Costs;, Official Use Onl
Labor and Materials) Y
1. Building $ (Q) L4 79 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: $
Check No. Check Amount: •Cash Amount:
6. Total Project Cost: $ (� ) 7 ❑.Paid in Full ❑Outstanding Balance Due:
fV I At t.eD `1 I Z'1 vz) C' ,L
f -
SECTION-5; CONSTRUCTION SERVICES.' 7 .
5.1 Construction Supervisor License(CSL) .
1� Li
- Z ) cense Expiration Date
1,51 i n ha
Name of CSL � t T Description
V � Unrestricted to 35,000 GLL Ft.)
Ad s Restricted l&2 Family Dwelling
M Masonry Only
i
RC Residential Roofing Covering
WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance
Telephone D I Residential Demolition
5.2 Home
�Improvement Contractor Registration(HIC) /
�Ji.4 s-'e 11 i'e p S Regisi ation Fxpiration Date
BIC Company N e or EEC t Name
-r .S c . MA ol��
:..
Signature
Telephone
SECTION 6:--:WORKER?SCOlYITENSATIONINSURANCE;AFFIDAVIT(NLG: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 Nor,0 '
SECTION 7a."'OWNER AUTHORIZATION,TO BE-CON TLETED WHENIOWNER'S AGENT:OR '..
CONT ItACTOR ArPPLIES.FOR BUILDING PERMIT=
as Owner of the subject property,
hereby authorize ��/2l�l Cep to act on my behalf in all matters relevant to work
authorized by this building permit application.
�, ) 17
�o K
Signature of Owner Date
SECTION 7Ii: OWNER OR AUTHORIZED AGENT DECLARATION :.
I, VU Z as Owner or Authorized Agent,hereby declare that the statements
and information fore application are true ands accurate,to the best of my tozo Ledge and belief.
Signature of Owner or-Affthorized 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 CNIR 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 soli¢waste disposal facility as defined by MGL c111,§
150a. Zuj�� Al 11�IVQiCA 04+
DEBRIS DISPOSAL LOCATION I
SIGNATURE OF APPLICANT 'ZY
6 .
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 PC)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.
Certificate No: A044625
I
THE CON1 %IONWEALTH OF N/LASSACHUSETTS
= g ExECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT j
_ ,,� r., DEPARTlm1ENT OF LABOR STANDARDS
� '`:'',
=j {�
19 STANIFORD STREET,BOSTON,NLASSACHUSETTS 02114
LEAD-SAFE RENOVATION CONTRACTOR LICENSE
I
I
A&A SERVICES,INC.
I 115 NORTH STREET
j SALEM NH 01970
LICENSE: LR002749 EXPIRES: Thursday,August 20,2020'
I
IN ACCORDANCE WITH M.G.L. C. 111, § 197B(b)AND 454 CMR 22.04,THIS LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR STANDARDS TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF
ENGAGING IN LEAD-SAFE RENOVATION.
THIS LICENSE IS VALID FOR A PERIOD OF FIVE(5)YEARS.
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR IN ACCORDANCE WITH M.G.L.C. 111,
§ 197B(b)(2)AND 454 CMR 22.04 WHEN ENGAGED IN LEAD-SAFE RENOVATION AND/OR
MODERATE-RISK DELEADING WORK.LEAD SAFE RENOVATION CONTRACTORS MAY NOT
PERFORM MODERATE RISK DELEADING WORK UNLESS THEY EMPLOY A SUPERVISOR,WHO HAS
TAKEN THE REQUISITE TRAINING AS REQUIRED BY 454 CMR 22,00,TO OVERSEE THE WORK.
V4
_ -RNl AMD.IVICKiNNEY,DIRECTOR
Massachusetts Department of Public Safety
� Board of Building Regulations and Stand"arils
Office i�(('onyumer Affurs 8c(;n9111133 Reculatinn License CS-057733, # -
I,
� hr `,(�HOME IMPROVEMENT CONTRACTOR Construction Supervisor
- I9 Registration 10.1609 Type:
h� :.
1 Expiration:.Expiratiow.i. 48 Private Corporation CHRISTOPHER ZORZY
- = 115 NORTH ST I;
A&A SERVICES INC' F 1P, SALEM MA 0197d x
Christopher Zorzy
115 North Street
/f �f/ ��
Salem,MA 01970=. ��C j Expiratan.: E
Lhttiersecrttitry <..CommISSlOner 05I26F2019 l
IA&A SERVICES,INC.
115 NORTH STREET
SALEM, NH 01970
I