7 LARCH AVE - BUILDING INSPECTION (2) �V The Commonwealth of Massachusetts
rd of Building Regulations and Standards I e llz
Boa
I V Massachusetts State Building Code, 730 CMR, 7"' edition 111 Vle'll'.\LI"IY
It Building Permit Application To Construct, Repair, Renovate Or Demolish a H, S,l hu'n1,u%
O < or Tu u-Family Dtrellin,l 1. 'nu,\
Th s ction or Official Use Only
Building Permit Nw her: Date Applied: `✓- •
s
Sinn:cure: O V ---
rp
Buildiug Ck nun ..Sinned euw of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Properq Address: 1.2 Assessors Map & Parcel Numbers
1.1a Is this an accepted street? yes no Map Numher Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
,7_.nua:r: i>Ia.^..t P:cpnsrd IJsr 1_ot Ar a s.s:j li) Frontage ;(t,
._ t _
i.5 Building Setbacks (ft)
----
Front Yard Side Yards Rear Y;uJ
Required Provided Required Provided ReyreireJ_-__�__ W.uciJ,'J
I � I
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: __ Outside Flood Zone''
Public Private❑ Check if yes❑ Municipal On site Jislwsal syaeln ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 OwnertofRecord: r� '7 Lard
e , a�t�•�9—_C_a -
PJu ('hriu ), Address For Service: ---
`"" %0-1- ZS2 -�045
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
F New Construc!iun ❑ Existing Building ❑ Owner Occupied ❑ Repairs(s) ❑ Alterauon(sl ❑ Addition ❑�
Demolition ❑ Accessory Bldg. ❑ Number of Units TOther Speer
iy:Frer)n�_Rell<�_Slinhq� .t Ter 4-
Brief Description. of Proposed Work':_/� �At�-ef' S ux i��_�S_�ii_�._ 14---��r�
iti __apt ex2 —L--r0_vsa !6r j — r-
� S:�ir,�1-��-�5;�.. t- � -�o�.�---R d t G l�us es 1-2 ✓�✓_�.'�--- ----- -- i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building $ I. Building Permit Fee: $ Indicate how fie is determined: !
❑ Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost (Item 6) x multiplier x
3. Plumbing
5 2. Other Fees: $��r� h
4. Mechanical (HVAC) $ List: Cl
5. Mechanical (Fire $ -
Suppression) Total All Fees: S
g Check No. Check Amount: Cash Allt�rtinn
J _
b. Total Project Cost: $ � 3Q•7 0 ❑ Paid n Full ❑ Outstanding Balance Due:___
L
SECTION 5: CONSTRUCTION SERVICES y
5.1 Licensed Construction Supervisor(CSL)
License Numher lixpilunou Date ,
Nunn•of CSL- Milder
List CSI_ Type(see heluwl
Wdrns Type Descri pion
C UnrestriemJ (Up to ii,tN)U Cu. Pt,)
R Restricted !&'_ Family D�kellinc
Signature M \Iasonry Only
RC Residential Roolin g Co%enne
Telephone _ _ \\'S Residential N'mdm% and Snli1ie _
SF Resiolcimal Solid Fae! liumine :\ >>lianer Inst-III,uum
D Re,identi:d Demolition
5.2 Registered Home Improvement Contractor (HIC)
IiLC Company Name or HIC Registrant Name Registration Number --
Address
Expiration Date
Signature Telephone
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
►._ as Owner of the subject property hereby
authortze _____ to act on my behalf. in all matters
this building permit
ielaGve:o work authorized by g p application.
i
Signature ui Owner Dote _
^� SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
1, �tT rn�,rA vC kCJ , 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. /� 1
vl�l to vtn r
Print_-a
11
Signature a! 0e%ner o,•Au:honz d Agent � .. Date _(Signed under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered con racror
(nut 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 Proarun and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I IO.RG and I IO.RS. respectively.
2. When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including garage, finished basemen attics,decks or porchi
Gross living area ISq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of halt/baths
Tvpe 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 SM.E.M
PUBLIC PROPERTY
DEPARTMENT
K1f01kilLY D�w'ry .
NAvo� 1 130 WA%dNGTC"S MEET•SM N SACHLserTS 01970
TFL 97474S-959S * Fn7c 979.7a49&M
HOMEOWNER LICENSE EXEMPTION
Please Print
Date S-2(— of
Job Location 7 L-a rr k 4 V 2
Home Owner Address I-. A- u�-A
Home Owner Telephone
Present Mailing Address 7 L a rc A v-z
The current exemption of"Homeowners"was extended to include owner-occupied
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.
DEFDffnON OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she 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 foam 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 "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 requirem ts.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code