10-12 CUSHING ST - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts
a*,b Board of Building Regulations and Standards CITY OF
\ICJ Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
00 This Section For Official Use Only
Building Perm t Number: Date App(ieed:
Building Official(Print Name) Si ature Date
SECTION 1: SITE INFORMATION
1.1 Pro a Address: 1.2 Assessors Map& Parcel Numbers
I^ iio- �51,A S4, Salpm hA
L la Is this an accepte heet?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: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑
Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑ I
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner f Record:
Name(Print) City,State,ZIP f
10-IX C6k, L45 f fir' `� 13' 313
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 Pro po d Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
1. Building $ d I. 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:
S. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 9 V-6rD ❑ Paid in Full ❑Outstanding Balance Due:
(�/k t t1e'p I C) i ed q-v A fy
SECTIONS CONSTRUCTION SERVICES.
5.1 Construction��--Supervisor License(CSL) -
�.A v IC' r)ho LiceoseG)-[-�-7-7 0j Expiration Date ? o
Name of I (�� A,, G '` T Desm 'on
c�E •Q I M I (7V U Unrestricted to 35,000 C1 FL)
Ad Ratified 1&2F Dwelling
M Masorty Only
i RC Residential Roofing Covering
pi -7 G� 'l C/1 Dc./'l(` WS Residential window and Siding
I / !) / �7 1 Ol T SF Residential Solid Fuel Burning liana
Telephone D Residential Demolition
5.2 Home Improvement Contractor Registration(HIC)
Registration Expiration Date 6 6
HIC Coon yN or HIC Re ' tName
Address
ZT, S
3ipmnue
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 a vit may result in the denial of a building permit
Signed affidavit attached? Y. No 0
SECTION jai OWNER AUTHORIZATION TO BE"COMPLETED WHEN OWNEli'S AG ENT.OR
CONTRACTOR A_ PPLIES.FORBUILD INGPERMIT
I, 1 c"01 t CA r as Owner of the subject property,
hereby authorize In j0, )?go(CPS to act on my behalf in all matters relevant to work
authorized by this building permit application.
Signature of Owner Data
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
I, P,twisIlI Y- Z4 as Owner or Authorized Agent,hereby declare that the statements
and information Vfore application are true a d accurate,to the best of my knowledge beIIef.
to'
6
Signature of Owner or A orized ent (Signed under the pains and penalties of perjury) Dare
i
SECTION 8: DEBRIS DISPOSAL'
All dumpsters of six(6)cubic yards or more are resuired 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 lice�nsed soli¢waste disposal facility as defined by MGL clll,§y
DEBRIS DISPOSAL LOCATION
SIGNATURE OF APPLICANT I o I
NOTE .
An Owner who obtains a building permit to do his/her own work,or an owner who hives 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.
a 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR
Regulations.