15 BALCOMB ST - BPA-16-240 INSULATION i �, o
The Commonwealth oftblassachusetts
Board of Building Regulations and Standards CITY OF
SALEM
W
Massachusetts State Building Code, 780 CMR Revised b4v 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
N This Section For.Ofliciai UseOnly.;; `. -
pfluild
mit Number. DatnApplied ):•.#;_, :. , ,,
31
icial(Pont Name) - - - Si ore Date
SECTION 1:SITE INFORMATION.*
1.2 Assessors dlap J@ Parcel Numbers
accepted street?yes_ no Map Number Parcel Number
1.3 Coning Information: 1.4 Pr erty Dtmeh�Clonsi ,
Zoning District Proposed Use Lot-Area(sq it) ,Frontage(11)� .. -
1.5 Building Setbacks(R) -
Front Yard. - - Side Yards - Mdlspwsdsystem
Required Pmvided Required Provided. Required1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage DispPublic❑ Private❑ - Zone: _ Outside Flood Zone? Munleipn 1 p On s
Chedtlf es❑_ .-. .
SECT_IO142. PRO
PERTYOWNERSIIIPk
2.1 O vnert of Record:
thme(Pont) 9 - - Cit state"ZIP - - - -
1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED_WO
RK=(check all that apply)
New Construction❑ I Existing Building❑ Osveer-Occupied ❑ ,Repairs(s) ❑ Altemtion(s) 0 Addition ❑
Demolition . ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of roposed Work':
o s
SECTION a:ESTIMATED CONSTRUCTION COSTS - . -
Itcun Estimated Costs: - - - ®ff7cial Use Only
Lab o and Materials) y
I. Building S -G0 , , I. Building Permit Fee:S Indicate how fee is determined:
2.Electrical S ❑Stv+dnrd City/Town Application Fee-
❑Total Project Cose(Item 6)x multiplier x
3.Plumbing S ? Qther Fees: S
4.Xlechanical (HVAC) S - - List: -
5.i\lechanical (Fire
Su ressiun) S Total All Fees:S -
6. Total Project Cost: S $ Check No.adQ%ChecicAmount: Cash Amount:
Paid in Full ❑Outstanding Balance Due:
t`f�6a t LrEQ
I
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License- amber Expiration Date
Name of CSL Holder List CSL Type(see below)
Eric N.Palm Type . oeseripliah ,
No.;old Strect 3 1 toII tTeet U Unrestricted Ouildin a to 35,On0 cu. Il.)
$a era KA 01970 R Restricted I&2 Famil D\vellin
Cityrrown,State,ZIP M ODfi R
RC oolin Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
q-7 g- 71411- SAH 3 Demotion
Tole hone
Email address D Demolition
5.2 Registered Home improvement Coutr actor(NIC)
IIIC Registration Number Expiration Date
HIC Company Nam IC egi N
Email address
No.and Street
Ci w/Ton State ZIP Tele hone
SECTION6rWORKERS'.COhIPENSAT.IONINSURAWCEAFFIDAVI'E(IVLG,I: c:13Z. 2$C(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 isiftlanceifte building permit.
Signed Affidavit Attached? Yes.......... No...........0
SECTION 7n:OWNER AUTHORIZATION TO BE COMPLETED W HEN:::,".
ONVNER'S AGENT OR CONTRACTOR APPE tES FOR BUILDING.PERb1IT'
1,as Owner of the subject property,hereby authorize
�rr`c P� lfYr -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Date
Print Otmcr s ame(Electronic ignature)
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
contained in this application is ue and accurate to the best of my knowledge and understanding.
Dote
print Owner's or, uthonzcJ Agent s Nano( ccuonm Signature)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,ai an owner who hires an unregistered contractor
(not registered in the Pond underome,I arbitration
rM.G Lnc142A.Contractort t l-(5-rfannt informtnTton on the HfC Progrl not have access to e—am can be7o`tiu 173t- —"
pNgram Of oaaraary
\aww mass aoy.!oea information an the Construction SupervisOt License Can be found at Ww\\'.I11ai5.2UV/dD5 .
2. When substantial work is planned,provide the inform c di b ow:age,finished basemendattics,decks or porch)
gar
'rotal floor area(sq.ft.) Habitable room count
Gross living area(sq.R.) Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms ,lumber of decks!porches
'type of heating system Enclosed Open
'rype of cooling system
3. "Total Project Square Footage"may be substituted for"futal Project Cost"