B-20-632 - 0035 BALCOMB STREET - Building Permit The Commonwealth of Massachusetts
Y'
it, Board of Building Regulations and Standards CITY OF
�l! / Massachusetts State Building Code, 780 CMR SALEM
r_ Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
'0 This,Section For Official Use Only,
Building Permit Number: Date Applied:
1
Bui ding Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1:1 Property ^es���� � 1.2 Assessors Map&Parcel Numbers
Lla 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: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
F rands A Bu1*'4'r6haw _,�a tpm- M itl Quo
Name(Print) City,State,ZIP
35 Rod CCr1)b_S+ 97931 tt)�PnPMad Cam
No.and Street Telephone Email Address
SECTION 3:.DESCRIP..TION OF PROPOSED WORKZ(c.heck all that apply) -
New Construction❑ Existing Building❑ Owner-Occupied�l Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Number of Units Other Specify:
':
Brief Description of Proposed Work
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: '
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(Item.6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su cession Total All Fees:.$
Check No. Check'Amount: Cash Amount:
6. Total Project Cost: $ pelk ❑paid in Full ❑ Outstanding Balance Due:
JUL 1 Am8:37
JUL
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2TR'e�g-issteerr'ed Home Improvement Contractor(HIC)
- /HIC Company Name or HIC Registrant Name y HIC Registration Number Expiration Date
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf,in all matters,relati,ve to work authorized by this building permit application:
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained inthis application is true and accurate to the best of my knowledge and understanding.
Print Owner's or'Authorized Agent's Name(Electronic Signature) ]bate
NOTES:
1. 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 can be found at
wwtiv.mas ov/oca Information on the Construction Supervisor License can be found at www.niass.goyid
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system t Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost" .'- -
} CITY OF SALEM, MASSACHUSETTS
-<< r BUILDING DEPARTMENT
98 WASHINGTON S`l."REET,2ND FLOOR
TEL: 978-745-9595
KIINMERLEY DRISCOLL
MAYOR
THOMAS ST.PIERRE
DiREc TOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION—
HOMEOWNER ADDRESS: 3.5 aw
PRESENT MAILING ADDRESS: aw
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two(2)units or less and to
allow such homeowners to engage an individual for hire that does not possess a license,provided that the owner acts as
supervisor.
Definition of Homeowner:
Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a
one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who
constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit
to the Building Official,on a form acceptable to the Building Official,that he/she be responsible for all such work performed
under the Building Permit.
The undersigned"homeowner"assumes the responsibility for compliance with the State Building Code and other applicable
by-laws and regulations.
The undersigned"homeowner"certifies that he/she understand the City of Salem Building Department minimum inspection
procedures and requirements and that he/she will comply with such procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR