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28 BALCOMB - BPA-12-15 REMODEL HOME, REMOVE FENCE The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF b Massachusetts State Building Coda, 780 CMR /�e1f`A 1EKI 6 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Fandiv Dselling This Section For Official Use Only Building Permit Number: ate Applied: 3 Building Official(Print Name) Signatur Date' SECTION I:SITE INFO ON Pygpert dtlfes�s:n / 1.2 ssessors Nlap& Parcel Numbers 1.1 a Is this an caccepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimeosious: Zoning District Proposed Use Lot Area(sq R) Fronlage(It) 1.5 Building Setbacks(R) 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 ifycsO SECTION2: PROPERTY OWNERSHIP' 2.1 ,Ine 'of R ord: m/U �ic�i� L L�s�► Sd1P-, AA V .v wne(Print) City,State,ZIP �yI I 8 Jp e/Con j .- /yf�L/�.>f1eii of'a'r cbh No.and Street 'telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply) New Construction❑ Existing Building❑ 1 Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: / Brief Description f P oposed Wor ': 4 rtp 'top. .a FG.act A V a X 9 a 4� E 'TION 4: ESTIDI. TED CONSTRUCTION COSTS Item Estimate sts: Official Use Only ateria`ls I. Building `1 Building Permit Fee: $ Indicate how fee is determined: © ❑Standard City/Town Application Fee _2. Electrical i ❑Total Project Cost'(Item 6)x multiplier x 3.'Plumbing S -1. Other Fees: S 4. Mechanird (IIVAC) S -- O List: 5. ,Mechanical (Fire S— — Su 1pression) Total All Fees: S Check No. _Check Amount: Crash Amount: XG Tutal Project Cost S �t ❑ Paid in Full ❑Outstanding Balance Due: --- a`CV(Q Il dn'm e b �f 73}�/ `Ar 1�R vt n a 110t�%`Ort s hR,l f� Y SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Fspiration Date Name of C'SL Ilnlder --- -- — -- List CSL'1'ype(see below) No, and sheet — 1)'Pe Description tl Unrestricted(Buildio S Up to 35,000 cu. 11.) ---- -- R Restricted Iffi2 Family Dwellin C'ilyi Ilon,Suue,ZIP M Mason ry RC Roofing Covering W'S Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address - D Demolition 5.2 Registered home Improvement Contractdr(HIC) L'C':cmea::y !tag err nIC Itagistram `<!.rte I IIC' Registration Number licpiration Date No.and Street " Email address City/Town. State,ZIP 'relc hone 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 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 contained in this application s true and accurate tot a bes o knowledge and understand i g. 'rl inn O�tn r'i or.\udturized AgenC::Name N lectronic Signature) Dale NOTES: I. 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. I 4?A.Other important information on the HIC Program can be found at goc oc:i Information on the Construction Supervisor License can be found at dpi 2. When substantial work is planned,provide the information below: Total fluor area(sq. R.) (including garage, finished basement'attics,decks or porch 1 Gross living area(sq. 11.) _ - Habitable room count Number of fireplaces _ Number of bedrooms Number of bathrooms Number of half baths ----------------- -- ------------------- T}pe ufheating system Number f decks porches— T)pettfcoolings}slem Enclose) -Open ........ 3. "focal Project Square Footage- may be Substituted for,,rolal Project Cost. CITY OF S.ULE.NI PUBLIC PROPERTY DEPART,LENT hu 6 Vwwe �e v strvar Suas�Nwetnoa�sns Olero raL 9'8.14i9s"•FAX 976-740.9646 HOMEOWNER LICENSE EXE.NPTION Phrase Prime Dale_ • Job Locadoe 2 g' t4 e! COPM! Home Owner Address 2 jZc_o-*r Sf Home Owner Talepne ho i< 33 9 'f �l Present Mailing Addresr 2 d' fflairpaA SP ea f"A 6 The current exemption oft"Homeowners"was extended to include owner-occupied dwellings of two Units or leas and to allow such homeowners to engage an individual for hire who.does not possess a license provided that the owner act@ as supervisor. DEFII MON OF HohMOWNML Persons)who owns a paced of land on which he/she resides or intends to reside, on which there is, or is intended to be4 a one or two hmily dwelHn& attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such •homeowner"shall submit to the Building Oillcial,on a form acceptable to the Building Official, that he/she be responsible for all such work performed under the Building PamiL The undaaigned"homeowner"assumes responsibility for compliance with the State Building"Code and other applicable by laws and regulations. ` The undersigned "homeowner"certifies that he/she understands the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requir nits. HOMEOWNERS SIGNATLRE ,APPROVAL OF BUILDING INSPECTOR '" ' See other side for state code CI-iY OF sm &Nf, IvLksSACHUSE-rrs Bt: Dc4c; DEP.IRTMEI':T 120 W.kSHLNGTON STREET, 3'0 FLOOR TM (978) 745-9595 F&X(978) 740-9846 KIJ®ERLEY DRISCOLL MAYOR Mows ST.Pmam DIRECTOR OF PUBLIC PROPERTY/8VUMLNG COMMISSIONER Construction Debris Disposal Affidavit . (required for aill demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 t 1.5 Debris, and the provisions of MGL a 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c l 11, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signatu[e permit applicant l% dale Ibnvl(J.c -