B-17-1230 - 0037 BALCOMB STREET - Building Permit The Commonwealth of Massa�chs'etls, '�
Board of Building Regulations and Sta FOR
Massachusetts State Building Code 780 CMR MUNICIPALITY
11 j T E� ��� USE
Building Permit Application To Construct,Repair,I en lle Ail.
a Revised Mar 2011
One-or Two-Family Dwelling
Thts Section por Official Use.Only
Building Permit Number Date plied:
13uddrng Official(Prmt Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
—� DA1- c,0y—�,3 i
lFZoning
lI accepted street?yes no Map Number Parcel Number
nformation: 1.4 Property Dimensions:
Proposed Use Lot Area(sq ft) Frontage(ft)
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?
Check if yes❑ Municipal W On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP
2.1 Owner'of Record:
\l'k A z k A O1-aa�
Name(Print) City,State,ZIP.
OvkL
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 01" Alterations) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: R;tv.,7 5�+., ,T(�t `ti
's 1J4:� h ��.w,S 3,� 16 a1 -Jul ' AS5 S-:ROJ )�-�� Casa, r(a_.atr
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OfScial Use Onl
(Labor and Materials - Y
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee ,,r.,�
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
r6.
Mechanical (HVAC) $ List: aPl�1
Zession
anical (Fire
$ Total All Fees:$
Check No. Check Amount: Cash Amount:
Total Project Cost: $ 13 Paid in Full 13 Outstanding Balance Due:
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ? 09 SI Ct(0 4� i
License Number_ Expiration Date
Name of CSL Holder
List CSL Type(see below)
l �v 3� A,y-ne
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
LL U R Restricted 1&2 Family Dwelling
City/Town, tate,ZIP M Masonry
RC Roofing Coverin
WS Window and Siding
SF Solid Fuel Burring Appliances
lk02:v 11�1U k lAi -5 ® I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) w
DSOs a, ��� en HIC Registration Number Expiration Date
HIC Company Name or HIC R�egiststrant Name
No.and Street Email address
CCi /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
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con ined in t ' cation is true and accurate to the best of my knowledge and understanding.
Prin er's or Authorized Agent's Name(Electronic Signature) Date
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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.f;ov/dns
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 r.- Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"