42 BALCOMB ST - BUILDING INSPECTION The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7a'edition OF SALEM
Revised January
Building Permit Application To Construct,Repair,Renovate Or emolish a 1, 2008
One-or Two-Family Dwelling
Altsl$ecfi no,,,rYlicra�Sls�, nly-
)3uiid�ngPerimitNurnber.
Signature � ,✓-^ 1/�/ !
' $bildmgCotmnisS�onerYlnspeetot" mldrh�s r - atc
Sl 0 rR(VIATI())JV
1.1 Property Ad ess:
P rtY 1 sessors Map&Parcel Numbers
'-.I a is thisan accepted street?yes_ no Map Number Parcel Number
3 Zoning Information: 1.4 Property Dimensions:
J '
Zoning District, Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
„ SECTION Z =°P13OERTi ?�ifNEI2SHt '
2.1 Owner'of Record:
Name(Print) Address for ervice:
�5�=�33
Signature Telephone
SECTIOP[3 DESCRIPTIC NON l 1F0POSE VOI IC$(cheek Wtnat apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Cl Specify:
Br of Description of Proposed Work':
SECTION 4 ESTIMr1TED4CQIY$TRUl TION,COSTS
Item Estimated Costs. OfScipLUse iDnlq
(Labor andMaterials v--
1.Building $ 1 Bui1'dingPerruttRee;:$' - 'Indicate-how fee is determined:
`❑Standard Ctiy4owfLApplicationTee
2.Electrical $
❑Tout Pr<ilect�s �(tem 6) multiplier x
3.Plumbing $ r(� p I peg
4.Mechanical (HVAC) $ efst` a
-
5.Mechanical (Fire $
Su ressionTalal AI#Rea
,Check#do• Check Amount. Cash Amount:
6.Total Project Cost: $ m Full- ;-q Outstanding Balance Due:
P -
SECTIQNt ` lNtrTti (S ;SBR�YCfS;
7CSL
struction Sup
ervisor(CSL) .
��.
4 -i -1
-�
;NmneP-L C l/� t�Gt_i License Number ExpimNonDate
r0,.tw ppLrst CSL Type(see below),p? -
_ U UnrestricteL uto 35,000 Cu.Ft.
Signature /" - R Restricted I&2 Famit Dwellin
M Maso Onl
Telephone / RC - Residential Roofin Coverin
WS Residential Window and Sidin
SF Residential Solid Fuel Bumin Appliance Installation
D sidtil
5.2 R islet H e I provement Contra et��IC) Re en a Demolition
LL io Fs rS�
HIC myNameor C Reg t e Registration Number
n m
Address
4.Lde..l� � 7�—�Cf.s-�'?(� Expiration DZ
Signature / Telephone
SECTIbN 6 V1 ORKERS'COMPENSATION INSURANCE AFFJDAVIT(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...........❑
N 7a:i4WNEI 11T1EIolIMATIQNT BFA
SECTIO
UFVNER'S AG ENTAR:CONTRAGTOR APPES F'qR=BUTT 111N -PERM)I , '
I' u J as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this buildin6permit application.
Si tureofOwner _ Date
AGENT DZ GL RATION-,;
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
L
Print Name
Signature of Owner or Authorized Aggpt Dale
Si nedpnder the ains and enalties of er'
NQTzTEs:
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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"