B-17-444 - 0028 BALCOMB - Building Permit s�
The Commonwealth of Massachusetts .l Y ,
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 MY 2:3 A C T 0SALEM
Revised Mar 2011
Building.Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied:
0 b-4L
O Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 PlopertyyAddress: 1.2 Assessors Map&Parcel Numbers'
aA tAtz
1.1 a 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 tt) 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 17 Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of R cord:
Naive(Print) City,State,ZVP
No.and Street Telephone Signature
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 Proposed Work:
�yo yw r S�N�PS J
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 'i9 1. Building Permit Fee: $ Indicate how fee is determined:
cdc
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. -Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: Fs
o;0 0 6 ❑Paid in Full ❑Qutstanding Balance Due:
5 K Olt U%9D 7b G 1 .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
2123 5/24/18
Glenn R Battistelli License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
11 Broadwa -R/P.O. Box 496
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
Beverly, MA 01915 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC I Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
—� (978) 927-8956 I Insulation
Telephone Si ature D Demolition
5.2 Registered Home Improvement Contractor(HIC)
172456 7/3/18
Glenn Battistelli LLC HIC Reg' ration Nu xpiration Date
HIC Company Name or HIC Registrant Name
281 Dodge St
No.and Street Signature
Beverly, MA 01915 978) 927-8956
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 Glenn Battistelli
to act on my b alf,in I matters relative to work authorized by this building permit application.
x -"of -7
Print Owner's Name(Signature) —f 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.=LkuQw1.edge and understanding. /
Glenn Battistelli 5vi L2
Print Owner's or Authorized Agents Name(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. og v/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"may be substituted for"Total Project Cost"