B-19-201 - 0042 BALCOMB STREET - Building Permit s.
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OR-- ,
`^e ' Massachusetts State Building Code,780 CMR SALEM
Revised Mar 20
Building Permit Application To Construct,Repair,Renovate Or Demolish a -'
/1 One-or Two Family Dwelling
�•^ ,/ This Section For;Official Use Only
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Building Permit Number.: Date Applied.
07
Building Official;(Print Name) Signature Date
SECTION 1:•SITE INFORMATION _
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1.1 Pr perry Address: 1.2 Assessors Ma & Parcel Numbers
42 rnb � 11 OQL-W.
L I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zonniing Information: 1.4 Property Dimensions:
R.L b r�1(�t4 n
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❑
-SECTION.1 PROPERTY OWNERSHIPI .
2. O"er'of ecord:
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Dame(Print) City,State,Z
L-42— ,IC�rnb S� i .-
No.and Street Telephone Emhil AddfJss
SECTION 3:DESCRIPTIONwOF PROPOSED WORK,,(check all tha"pply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition 0 Accessory Bldg. ❑ Number of Units Other l,Specify: `
Br'ef Description of Proposed Work2:
V�A0
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: b Official Use Only r
Labor and Materials)
1.Building $ i:'Buildtng Permit Fee:$ Indicate how fee is deternuned:,
O 13 Standard City/Town Application Fee
2.Electrical $ p Total Project Cost3(Itern 6)x multiplier x
3.Plumbing. $ D 11 Other Fees',$"
4.Mechanical (HVAC) $ O List:
5.Mechanical (Fire
Suppression) $ t/ Total A11 Fees':$
���- Check,N9 Check Amount Cash Amount
6.Total Project Cost: $ , 1
1 _ ❑Patd to malt 0 Outstanding Balance DueA.,
Joy i�ys I mk6oh ledmilCs Jive , m
SECTION 5: CONS TRUCTION:SERVICES
&I Construction Supervisor License(CSL)
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honorL �yrl k �I License Number Expiration Date
Name off CSL Holder --I+
List CSL Type(see below) .J
and Street 1(� (�1TYPe Descnptlon $
U Unrestricted" uildin gs up to 35,000 cu.ft.
V R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
I/�� SF Solid Fuel Burning Appliances
V I I o I Insulation
Telephone Email address D Demolition.
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Home Improvement Contr ctor(HIIF�2�1� Z
I om ��r , Re s N e HIC Registration Number / Expiration Date
W y 1 1t� lgrlyl ibima7 �C.1�ne�.AJr�`111
o. d Stree �.-+LAI, , (,�'�n„�,^( Email address COM
Ci own,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 UTHORIZATION•TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR'BUILDINGPERMIT
I,as Owner of the subject property,hereby authori Lam�
to act on my behalf,in all matters relative to work authorized by this bui ding permit'application.
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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 in this application is true and accurate to the best of my knowledge and understanding."
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Print Owner's or Authorized Agent's Name(Electronic Signature). Date
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 fiend under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.jzov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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 Number of decks/porches
Type of cooling;system Enclosed Open
3. "Total Project"Square Footage"maybe substituted for"Total Project Cost"