40 BALCOMB ST - BPA-09-839 REMOVE SIDING & INSTALL NEW f
1
The Commonwealth of Massachusetts
4Building
Department of Public Safety
la NNa Ch a scl lS State Building Code(780 C%IR)Seventh Edition
City of Salem
Buildin Permit A lication for an Buildin other than a I-or 2 amil Doavailable)
(ThisSection Fur Official Use Only)
it Number: Date Applied: d Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is no
x !�o atiGcoMCS Sl SAl�ih o/Y?b �/sSa
No.and Street Cit) /Town Zip Code Name of Building (itapplicable)
SECTION 2: PROPOSED WORK
It New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ Alteration Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being Supplied as part of this permit application? Yes ❑ No _
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 2(
Brief Description of Proposed Work: o - K fl 7,,It,6
.Tws�r9GL NEw /�al�1 /'L/4v/< cL�PQor9�a1 sTYC� PR8-PSD pie syr ••
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O
Existing Use Group(s): Proposed Use Group(s): g
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as ap livable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5 OT B: Business ❑
IE: El
F:: Facto F-1 ❑ F2 103 H: High Hazard H-1 ❑ H-2 ❑ H-3 13 H-4 ❑ H-5❑
13
I
Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 R-3 ❑ R-4 ❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use: "• ,-
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ 1116 ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
PP Y�
Public ❑ Cheek if uutsidu Iq n,.d Gme ❑ Indicate ani n.cepal ❑ '\ trench will not be 1_icemed Disposal tine ❑
1'11).ite ❑ or indentil)Zone:_ or on si to system ❑ required ❑or trench ur .(,reit):
pVrmn is enclosed ❑ _
1 Railroad right-of-waV: hazards to Air.Navigation: V:( I h>an,r t.nnmi��nm I:rno„ I'n
\,�! \pidii.�ble❑ I. tilrurture,)ohm au,nrt a > ,roach area.' b then reg ic�c cum ,
I f 4 I IeteJ,
,•r C 'mont lu Buil.i rolu"cJ ❑ 1•c.❑ or No ❑ Se* ❑ Nn ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
pe„I1,nDt ru C nun: l)CC ll pant Lund per I lune:
1),w, the buikfin};iunta,n an Sprinkler Sn stem': Special Stipulations: _
SECTION 9: PROPERTY OWNER AUTHORIZATION
Hann•.,i"nd ,\ddn>s of Property Owner
L OIIT ✓W GElydleo V Ifo Ml co m/S S'
:Name(Print) No.and Street Cih'/Town Zip
`^ Properly OAN ner Contact Information: `
J� o w/vdR cl 7,pa vG �i n B Gknd/kvy d✓�k;�
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner herebv authorizes
Name Street Address Citv/Town State Zip
to act on the pro pem owner's behalf. in all matters relative to work authorized by this buildin 6 permit a p plication.
r
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) ,
(It buildin•is less than 35.)0 cu. ft.of enclosed s pace and/or nut under CUnStrtLCtiUn Control then check here O and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address./ Registration Number
Street Address Citv/Town State Zip Discipline Expiration Date
10.2 General Contractor
x
Company Name:
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. (business) Telephone No. (cell) - e-mail address
SECTION 11:WORKERS'COMPENSATION LNSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC)'*,' $
5. Mechanical (Other) $ Enclose check payable to
X6 Total Cost (contact municipality)and write check number here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
Bv entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
applicati/on is true and accurate to the best,)f my knowledge and understanding.
X 601,,AG '�/ ?ON fY2��o^ Oc NE/� -7Ks"- .'/d69
I'lea>c print and >tgn name title Telephone \o. Date
!f� 6tIL�o� 9 ST rm /h14 Df92v -/3sz
Gtrurl :\ddre�s Cih;'Town Mate Zip
\lunicipal Inspector to till out this section upon application approval: -
Name )ate
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i0h