20 LARCHMONT RD - BUILDING INSPECTION r
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
,,� Massachusetts Stale Building Code, 780 CMR, T"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fmrtilt Divelling
This Section For Official Use Only
t CP Building Permit Number Date Applied: Z
Signature:
Buil ng Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 aOProperty AdQress: f /? 1.2 Assessors Map& Parcel Numbers
r c. vH r7 w / `�k >
I.1a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distnct Proposed Use Lot Area(sq R) Frontage(([)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L C.40,§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private E3 Zone:
if yesE3
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
20 '\/4rr�r / T J6�
Name(Print)
y Address for Service:
9-:4 Fr : q L/--1 d ir"5—
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief DescrirLo of Proposed Work=: *,C.K
�Cr�odCC-�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Oflielal Use Only
Item Labor and Materials
I. Building S I. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S Total All Fees: S
Su rescion
Check No. _Check An oune Cash Amount:_
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction
'Super%lso,�r^(CSL) p�t'lZ�
1 ✓r-�l�'l -v �"�/ License Number Expiration Date
Ngmc ol'CSLHpIJ�r 0 U
-L -) ��,$, S+- List CSL Type(sec below) V
Add css T Description
t�tq�leJ.e�Qe -U Unrestricted(up to 35,000 Cu. Ft.)
Signa R Restricted 1&2 Family Dwelling
M Mason Onl
RCResidential Roofin Covering
Telephone t-} WS Residential Window and Siding
�� SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 ,$e-gist Home Improvestnt Co�frac0tor(HIC) 11 Sc) r-7
HIC Con party Na�ot HI Registry Name (_ _ Registration Number
Address ll�` •+•�-
?!n (s 5S - o0 t-Lo Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 AtFdavit Attached? Yes .......... ❑ 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 �+•ti f/�lic-lam to act on my behalf, in all matters
relative to work authorized by this building permit application.
2
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT(DECLARATION
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
(Signed under the pains and penalties of riu
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. 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 IO.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 SALEM
37 �iiPUBLIC 13ROPRERTY
DEPARTMENT
♦+i', M 1 Y 111114,.1 1
13: ]I, lvt.0\_ws III it 1 INV17-
I'h.1. 773-71i9595 a 1:wx 97x-74::'I.N+
Workers' Compensation Insurance llifftdaxit: Hui ldcrslContractors/ElectricianVi'lumbers
%miticant Information Plcase Print Leeihly
NiuneC'c'ICAI
/ �-
1Jdrcss: � l •M� I ' r--
City,State.%ip(� `r�W-" 1017lit� I'hunc ;' [V — 10 �S —DC��(
\rr w so an employer'! Check the appropriate box: 'Type of project(required):
I :un a employer with 4 1 :un a general contractor and 1 6. gNew construction
.�1 -
//// nq>loycea(iuli unlL'ur pan-ante).a 1we hired the sub-contractors
2. 0 I am a sole proprietor or partner- listed on the attached.sheet. 7 ® Remodeling
ship and have no employees These subcontractors have V. (Demolition
working for me in any capacity. workers' comp. insurance. q. Building addition
No workers'cum . insurance 5. 0 We arc a corporation and its
I P 10.® Electrical repairs or additions
I required.) officers have exercised their
3, 0 1 ant it homeowner doing all work right ofexeription per bIGL I LQ plumbing repairs or additions
myself. (No workers' comp. c. 152, ¢1(4),and we have no 12.0 Ruuf repairs
insurance required.] r employees. LNo workers' 13.0 Other
romp. insurance required.]
• w n. .,gdwuul that cheeks box 01 must:dao fill wn the.eaten Iwluw rhuwiny their wurkus'cumpunvuiwl lwh y uaium:aiun
' I lomauwrwn who anbmil this 211 intlic.ning they are doing all work and then hire outside ceturacton must.uhmil a new ulCaavit indiubny umh.
-C ,,,je,cutn that check this boa mol u,txhed an aedtiunal nhein.Auwiuy the na,ne of the sub-contraelun and their wurken•amppolicy eiflarnadun.
/avn u11 r,upluyer Brut i.r pruvidit{t(rvurk¢rs'cuorprnrntion insurance fur wry eurplaiwes. Be/oly is rhe pu/fcy"1111fob vile
iufunnution. , �
In1nrJnLe Cuntpauy Menne: �'�• ----
I'nlicy A ser Sclsf- m. Lic. / h, G !9'O_CA_h 5._ Li O(Aooq_ .. -. E_w-p—ir-a-a-o_—n—Date-.
lul > te \dJres: XV �xI_� 'MOs \ City;JlataZl : �q
t Q�
.\trach it copy of the workers' cumpensatiun policy declaration page(showing the policy number and expiration date).
failure to secure Guweragc as require)under Section 25A of.%1OL c. 152 call lead to the imposition of criminal penalties of a
line if, (.t)1.5110,00 ant/or une-year ntprisnnincnt, as well as civil penulau in the farm of a STOP WORK ORDER and a fine
of up to 5250.00 is Jay .Igainsf the violator lie advtsccl that a copy of this statement may be Iurwarded to the 011ice of
Inw:.n•,au•+ro u(Jiu DIA :or io,ut.uxe wail icaUtn.
/du her,by t,rtify wider�re tuns mrd penultiev ufperprry but the information provided abuse is true and correct.
�/ —mak �,• I)aty�5 ��
c
')/Jiciul ese mdy. /)u oat write in Nis urea, to be rump/rte11 by airy or laevo„//itiu/. I
(rily ser fawn: __. _ Permit/Liecme 4
I„tiny; .\ulhurily (circle oae):
I. IH,.uJ of IIe.Ihh t. ISuddiuq Dcpuruneul 1, Cil .-Ib+ut Clerk J. Electrical luipcctor i, plumbin4 luvyeetor
6. Ot tier _
Phone it:
cis
Information and Instructions
N fassachusetts GcncraI Laws d,apter I Q requires all employers to provide workers' compensation for their employees.
Is r.u.mt to (:lis ,tame, an employee is defined as- .e,erg pci.son in the service of another under any contract of hire,
..press or impl,cd. oral or wrnten...
.\n :rnpluyer is defined as ''an individual, partnership, .ssociatiou, corporation or tither legal entity,or auy two or more
a the h,regowl; engaged of a joint enterprise. and including the legal representatives of a deceased cmpluycr, or the
receiver or trustee of .W Itldnvhduji, panttiershnp, association or Other legal cnnty,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
,I.vcllutg buuse of another who employs persons to do maintenance,construction or repair work on such dwelling house
or oil the.rounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer."
\IGL chapter 152. §25C(6) also states that "every$rate or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant:kho has not produced acceptable evidence of compliance with the insurance coverage required:'
Addinunally, �IGL chapter 152, §25C(7)Mates 'Neither the commonwealth nor any Of its political subdivisions shall
enter into any contract for the perfomiance uf'puhlic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Phase fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) nanic(s), address(es)and phone nunnber(s)along with their cerllficate(s)Of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other than the -
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP docs have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
.\ccidents for continuation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
Ile rcuhrned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or of you are required to Obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or'rown Omclals
plca.se he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
I'I,tasc be sure to till in the pcnnit/license number which will be used as a reference number. In addition,an applicant
that must submit in pennitlliceose applications in any given year,treed only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write ;'all locations in (city or
town).'' A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is On tyle for future permits Or licenses. A new affidavit must be filled out each
near. Where a Koine owner or citizen is obtaining a license or permit not related to any business or commercial venture
t i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I h.: t)i lice of [ovesri.atiuns would like no diank you in advance tar your cooperation and should you Base any questions,
,)[case do not hesitate to give us a call.
fhe D,:p.uuncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
OQice of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax p 617-727-7749
e_.:.rd ;-,t .u' www.mass.gov/dia
I�
CITY OF SALEM
s PUBLIC PROPRERTY
�,.. •� DEPART'VENT
L'; U "nn......<N! iIr ♦ \.\l i \I. \I I , ._I') :
III 'I'8 '4; I \"i'R.•4_ ' ]7i
Construction Debris Disposal Affidavit
(feyuired air all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CA'IR section 1 1 1,5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit h is issued with the condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
/ `1 ac,f� C V'�'+,
(name of hauler)
I he debris willl be disposed of in
CD l
(name of IacBity)
I�IJresv of I�cility)
a�natmc of p:nnu applicant