53 LARCHMONT RD - BUILDING INSPECTION The Commonwealth of Massachusetts
i Board of Building Regulations and Standards
Town of
r memo
Massachusetts State Building Code, 780 CMR, 7`h edition Building Dept
(� Building Permit Application To Construct, Repair, Renovate Or Demolish a
v One-or Ttco-Family Duelling
This
tt n For fficial Use Only
Building Permit Number to Applied: / n
Signature:
Building Commoncd nspcct vildings Date ----� T_
CTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
�z�''4'�C�A-�'r,.h.vc.•r-tr �=.nom-I'
1.[a Is this an acce ted street?yes 11._�o Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ill Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Raquired 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 yesO
SECTION 2: PROPERTY OWNERSHIP'
2. Owner ofRecord: f
,(.�"1�/�( ftCslA `�-Cdl.(K!/'( �.J C+t�J'�ltHzwtf �o.�-✓
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKt(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify:
Brief Description of Proposed Work=: K4v $Y+ 1 in 11
4SECTION 4: ESTIMATED CONSTRUCTION COSTS
item Estimated Costs: Official Use Only
Labor and Materials
1. Building b Soo 1 1. Building Permit Fee: E Indicate how fee is determined:
2. Electrical S G a ❑Standard City/Town Application Fee
3 fr'JU` ❑Total Project Cost (item 6)x multiplier x
J. Plumbing 5 2. Other Fees: S
4. Mechanical (HVAC) 5 List: f
5. .Mechanical (Fire 5
Su ression Total All Fees: b
Check No. _Check Amount: Cash Amount:
6. Total project Cost. 5 �� % 13 Paid in Full 0 Outstanding Balance Due:
a
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) a '-7 �}? j 2 'Z-�� �j-
r ! `f J —L
/�» 1�� License Number Expi atron Date
Ngme ol'CSL- Hpl/der / r. List CSL Type(see below)_
3 c rr Of!-rc A/fi r
T Description
A ess U Unrestricted u to 35,600 Cu.Ft.
-- R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RCPResi'dentialDemolifion
sidentiaRoofingCovering
Telephone wSsidentiaWindow and Sidin
SFsdentiaSolid Fuel 8umin A liance Installation
D
5.2 R�stered Home Improvement Contractor(HIC)
Ire 4 Inry
HIC Company Name or HIC R gistram Name ! Registratiopn/N{um�bjer
5— PGfx�_gZy
Add
{'s\� L—'->`� C Jt��y7�' �G/i/,�,/ Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 f 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.
Si nature of Owner Date
SECTION 76:OWNEW OR AUTHORIZED AGENT DECLARATION
�'(� r''
1 \`^"- n,,,,,.,_fj tv�. 7 ,as Owner or Authorized Agent hereby declare
that the statements and information on'tthe 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 2ains and penalties of r u
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 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 t 1O.R6 and 110,115,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
:lam:
PUBLIC PROPRERTY
DEPARTMENT
�I\1..1 :�1illr � \.t� � �l.
Construction Debris Disposal .-Affidavit
(rcyuiied lir all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CAIR section 111.5
Debris, and the provisions of.NIGL c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
ALL
I nam•of hauler)
I he debris will be disposed of in :
IRk#6
(name of lacility)
l addrex<1)(racllilvl
+IL'l1 al Ul l' Ut I)i rlll if .I I)I)IlC allt
daw
CITY OF S.1I. -Ims ANSSACHUSETTS
BuILDLNG DEPART%m T
oxawA
1'_0 WASHINGTON STREET. 3'O FLOOR
TEL (978) 745-9595
FAx(978) 748-9W
KINfBERLFY DRISCOLL THONIASSTTIERRB
MAYOR
DIRECTOR OF PUBLIC PAOPEATYf HL'B17LVG CO\(!%tISSlONER
Yorkers' Compensation Insurance Affidavit: Builders/£ontractors/ElectricianslPlumbers
Anplicant Information Please Print Lea'iib"l_Y
Naive tBusim� organiratiotvindrvtdual): !Lir 6 V4^ Cif— C",4-2 11'r-Al Le
Vr.,,,Sf 1G&em(i �k r Y
CityiState/Zip: !?S �el�t V44 <f" Phone i#: All 6/ /7" 114r 3 4
11
Are yo n employer?Check the appropriate box- Type of project(required):
1. 1 am a employer with 4. Q tarn a general contractor and 1 6. Q New construction
employees(full and/or Part-time).* have hired the sub-contracuirs
2.Q 1 am a sok proprietororor partner- listed on the attached sheet t ? ❑Remodeling
ship and have no employees These sub-contractor have 8. Q Demolition
working for me in any capacity. worker'comp.insurance. 9, Q Building addition
(No worker'comp. insurance 5• Q We are a corporation and its 10.Q Electrical repair or additions
required.] officers have exercised their
3.Q 1 am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repair or additions
myself. [No worker'comp. c. 152,§1(4),and we have no 12.Q Roof repairs
insurance required.]t employees. LNo workers' 13.0 Other
comp.insurance required.]
'Any applicant Ihai checks boa nt must also fan""he section below showing their worker'comQenearion policy ntfurmadon.
'1 Latxrswtamt who submit this affidavit indicting ihay are doing all work and then hitt otnsidn contractors mat suhmil a new amdsvil indicating such.
=(".ntrsyon that check this box must attached sn additional sheet showing the Hunt,of the sub-contractors std their workari comp,policy intarmution.
I am an employer that iw providing)vorkers'comperrsation Insurance for my employees. Below is the policy and Job site
information. r^
Insurance Company Name: of_ -'� G' R'
Policy#or Sclf-ins.Lic.. 4o(f,,o 12-fe Expiration Date:
Job Site Address: __c ✓/%�/f�fC City/State/Zip: _
Aclack a copy of the worker'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$ 30.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
7 do hereby certify uncle pis s andMiresperjury that the information provided above is true and correct.
774^� �sc (Jute:
Phone#:
Official use only. Do not write in this urea, to be completed by city or town official
E
City or Tuwn: _ ___
issuing Authority (circle ane):
1. Board of death t. Building DeparIntent 3.City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ ._-- -- Phone#:_
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