30 BALCOMB ST - BPA-10-704 UPDATE KITCHEN & BATH 1
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FRevisedJanuars
]y� i Massachusetts State BuildingCode, 780 CMR, 7ih edition
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This tion For Official Use Only
Building Permit Number: ,i e A plied: 1 II t ) 0
Signature: �• ( u. L t7
Building Commissioner/Ins for of Bu Idi Date
SECTI0MfJ SI E INFORMATION
1.1 Property Address 1.2 Assessors Map& Parcel Numbers
.2n /La/&:2'"43-5/
1.1 a Is this an accepted street?yes LZ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) Frontage(tt)
1.3 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 01'� Private❑ Zone: _ Outside Flood Zone? � �
Check if es❑ Municipal O'On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O er'of Record:
Name(Pn Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building UKOwner-Occupied Repairs(s) Alteration(s) DfAcklition ❑
Demolition ❑ Accessory Bldg.Cl Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work 194TC7 K/
S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials)- 011iclal Use Only
I. Building S (yfDO 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:_
5. Mechanical (Fire S
Suppression) Total All Fees:$
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CS*nd
ber Expiration Date
Name of CSL-Holder e(see below)
Description
Address nrntricteJ u to 35,000 Cu.Ft.
estricted 182 Family Uwellin
Signature aw Only
esidential Roolin Coverin
Telephone sidential Window and Sidin
esidential Solid Fuel Bumin A liance Installation
esidential Demolition5.2 Regbtered Home Improvement ContraIi1C Company Name or fIIC Registrant NameRegistration Number
Address Expiration Date
Signuture Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152. 1 2SC(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..........O No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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.
Signature of Owner Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
a�grl (N. //ioitrsl as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Sixned under the pains and penalties ofperjury)
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 aoj have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
CITY OF S.ULE.NI
PUBLIC PROPERTY
DEPARTMENT
wvo. e]oWA9dP1GrMsneer9IMAKVwaA04LSW s019'e
rm rs-745-95"9 FAX 978-746964
HOMEOWNER LICENSE EXEMPTION
Please Tritest
Job Locados 4/60 A,,
Home Owner Address Ste!£
Home Owner Telephone 97 S - 7 6 7-A-7 d
Present Mailing Address 3o Zia e,> h 6 ,;
The current exemption of"Homeowners"was extended to include owneroccupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) who owns a parcel of land on which halshe resides or intends to reside,on
which there is, or is intended to be, a one or two family dwelling, 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 Official,on a form acceptable to the Building
Official. that he/she be responsible for all such work performed under the Building
Permit
The undersigned "homewwna l 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 heshe
will comply with said procedures and r�
HOMEOWNERS SIGNATURE
Y
APPROVAL OF BUILDING !.INSPECTOR
See other side for state code
�A CITY OF SALEM
1- . • PUBLIC PROPRERTY
DEPARTMENT
\I .I•'M 11f}� �+111.\L. !V�I'M l•.l'i f),III M,%1.\»At 111 V I,+.I" .
ffl v7t•NS•1}yy 1:.%tt:971•744'18*
Construction Debris Disposal Affidavit
(required l'or all demolition mid renovation work)
In accordance with the sixth edition of the Slate Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit q is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal racility as der
by MGL c
I1l. S 150A.
The debris will be transported by:
(name us hauler)
Hit debris will be disposed of in
(name of f36hq\/
(addrl"Iof facility)
+Ignature of lxrmit applicant
Jate