87 BARSTOW ST - BPA-16-1332 REPLACE 3 WINDOWS � zS
j The Commonwealth of Massach`OVWP M L
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 7NOM U P 4' 43 S
ALEM Revisedd Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
C� One- or Tivo-Family Dwelling
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This Section For Official Use Only
Building Permit Number: Date Applied:
' Building Official(Print Name) Signature Date
SECTION 1: SITE INFORNIATION
1.1 Prope�y�jTy Address: (� 1.2 Assessors Map& Parcel Numbers
Wrl I_SGIi'_SM � JdleYl7r MA
1.to Is this an accepted street?yes no Map 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: (L1vLG.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Ow ert of Record:
�� it �-Ao 4�)aMiJ AAA- 01 q �o
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) ❑ 1 Alteration(s) Addition El—
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work-
- JQP (�m
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item s
Estimated Cost
Labor and Materi
als) Official Use Only
1. Building $ O d 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 (RVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
r� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ l rl 0 Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES '
5.1 nConstruction Supervisor License(CSL) —���� >�
License'} cation Date o
Name of/ 64� n,�' �y ,`
/V c3-1 1 /✓' /7v Type-,
Umatictrd to 35,000 Co_Ft)
AddrWs Restricted 1&2 Fstaily Dwelling
M Masonry Only
i RC Residential Reefing Covering
ws Residmtial Window and Sidingq -/ _ - SF Residential Solid Fuel Buming Appliance
Telephone D Residential Demolition
5.2 Hom)�e Improvement Contractor Registration(MC) /
4 i4 ,Leg y1 (mot+ p,S' Registration�l ()I Expiration Date Ip 6
MC com N e or fI1C Registrant Name r,
r J
Add ess
Sippat=
Telephone
SECTION 6: :WORKER'S COMTENSATIONINSURANCE AFFIDAVIT MGL c.452. §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 0
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT:OR '..,
CONTRACTOR APPLIES FOR BUILDING PERMIT
(A U ,as Owner of the subject property,
hereby authorize Se/j V L to act on my behalf in all matters relevant to work
authorized by this building permit application.
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Signature ofOwnm Date -
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent,hereby declare that the statements
and information Yfoirei application are true ana accurate,to the best of my knowl dge Ind belief.
SignahueofOwnerorA oriud ent (Signed under the pains and penalties ofpajury) Dare
SECTION 8:. DEBRIS DISPOSAL
All dumpsters of six(6)cubic yards or more are reanired 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 soG�waste disposal facility as defined by MGL c111,§
150a. ZUj�t pi'
DEBRIS DISPOSAL LOCATION
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 Construction Supervisor Licensing(CSL)can be found in 780 CMR
Regulations.