20 BALCOMB ST - BPA-12-957 MINOR REPAIRS � t
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
1 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 Applied:
l7h b�mc��
Building Official(Print Name) "gn e Date
SECTION 1: SITE I FORMATIO
1.l1 P erty Addpcss, , i r r — 1.2 Assessors Map& Parcel Numbers — --
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 ft) - Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided I-,I-
1
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 ❑ r
Check if yes[] _
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of R�cor ---- -----
Name(Print) City, State,ZIP
l0 (.?Ch
4�1 X��L1 _�J
Nia-Ld Street Telephone Ema
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ .Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg, El NumbecofUnits— Other ❑ Specify:_________
Brief Descnpti not Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
_ Labor and Materials
L.Building $ 1. Building Permit Fee: $_ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $
❑Total Project Cost (Item 6)x multiplier___Y._
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: $ Q ❑ Paid in Full ❑Outstanding Balance Due:
F",L) D -r6 OWL)K,(2 r.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
rl 5 License Number Expnatuni bate
Name of CSL Holdell
1L5 ��� � �_ List CSL'fype(see below)
No.and Street Type Description
JtM U Unrestricted(Buildings u to 35,000 cu.ft.)
I ' 1 ICJ R Restricted 1&2 Family Dwelling
City/Town,State,ZAP M Masonry
RC Roofing Covering
WS Window and Siding,
9�18`l�/I OU2 SF Solid Fuel Burning Appliances
I Insulation
ele hone E l address D i Demolition
5. Reg/issteredd Home
/Improvement
nContractor(HIC)
C)—(—tad,Kf V (M I1 `v i H!-.RegistrationNumber Vratio Date
H C C mpany N me I-11 rst�Na e
.a S t n 1 1ng I L4 L"mail address
City/Town,State,�IP �( 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 Issuan e 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,he authorize -- _ _
to act on my behalf, in all matters relative to work authorized by tM building permit applicati
oaJ
Jm&)d TIo,fllt, 51 ice I
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
contained in this application is true and accurate to the best of my knowledge and understanding.
r s gName—(Electronic/ 1' 7 lJl ) at
Print Owner's or Autho zcd Agent's Si at 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.ntass.gbv/oca Information on the Construction Supervisor License can be found at www_nlass.. Pv_!dps
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"