7 LARCH AVE - BUILDING INSPECTION (3) as-
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The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
1 Massa Revised Mar State Building Code, 780 CMR SdMar
1Il'/I 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
1 One- or Two-Family Dwelling '
This Section For Official Use Only
Building Permit Number: D Ap 'ed:
uilding Official tPrint Name) 1, Sign Date
SECTION 1: SIT ORMATI
1.1 Property Address: e- 1.2 Assessors Map&Parcel Numbers
�_1�,�'hi Av
1.1 a Is this an accepted street?yes 4e- no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use - Lot Area(sq ft) Frontage(ft)
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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private❑ Zone: _ Outside Flood Zone? MunicipalJ9.On site disposal system ❑
Check if yeso
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
8 cL SA-er-; t MA 0 (g7O
Nam (Print) City,State,ZIP
_7 I",arr ,r Ate-.
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply)
New Construction ❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s)19 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
4L4L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 9 �� - FStandard
g Permit Fee: $ Indicate how fee is determined:
2.Electrical $ City/Town Application Fee
roject Cost (Item 6)x multiplier x
3.Plumbing $ O&V- — ees: $
4.Mechanical (HVAC) $
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ !?ev _ 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
J eu.4 eo� 0 _ License Number E uatio Date
Name of CSL Holder
List CSL Type(see below) L1
No. and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
V R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
INS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(MC) L7
S(Jc�IV'OUWtSTLUS CRegistratio Number xpirtionDate
HIC Coparry Name or HIC Re strant Name
C)L''�1/�A trYrn�'S si9l.[Lmam$ lbs 49Awc- -C.2 it
No,and Street Email address
City/Town, State ZIP 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 ...........lY No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES
(jFOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize Pip I t°(/(J t i 1 VcPat
to act on my behalf,in all matters relative to work authorized by this building permit application.F
Date
Print ner's Name(Electronic Signature)
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
PeAew 6`'t 3(,:&K /P -/3
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass.eov/dna
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"
i CITY OF S�XI.E%4 2AXSSACHUSETTS
• BUILDING DEPAEMIENT
• p 120 WASHINGTON STREET, 3'o FLOOR
b� TEL. (978) 745-9595
FA.r(978) 740-9846
KIMB Ri EY DRISCOLL
MAYOR TrIOr`tAs ST.PIERRIi
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMSIONER
Workers' Compensation Insurance Affidavit: Builders/ContractorsiElectricians/Plumbers
Applicant Information Please Print Leeibly
�j >
Name(Business,Organizatiotvindividual):PE l i a� L J,1hbZt6lk A�tle. C i 7 w Lynn n.. "DI—LS
Address: (a(a le slap arK
City/State/Zip: s�r MA U to70 Phone //:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ l am a general contractor and 1 6. ❑New construction
ployees(full and/or part-time).* have hired the subcontractors
2.0 1 art a sole proprietor or partner- listed on the attached sheet.: ?• 0Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself. [No workers'comp, e. 152, g 1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers' 13.0 Other
comp. insurance required.1
Any applicant that Checks box 91 most also fill out the action below showing their worker'compensation policy information.
I h,meuwnrn who submit this affidavit indicting they ate doing all work and then him outside contractor,must submit a new affidavit indicating such
=Cantm.xon that check this box mtnt attached an additional short showing the name of the sub- raracton and their workers'comp.pot icy infomution.
I am an employer that is providing workers'compensation hisurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy 4 or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 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.
I do hereby certi under the ppuuulln�s and enahles of perjury that the information provided above is true and correct
Sit! ature• C/ Date: /,/tP•i3
Phone X: 97,e 77/
Ojjcial use only. Do not write in this area,to be completed by city or town oJreiaL
City or Town: Permit/Licenge# __
Issuing Authority(circle one): T
1. hoard of Health 2. Building Department 3.City/fawn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ Phone#:
CITY OF SM EM, NLkSSACHUSET rS
BU LDLNG DEPART\MNT
• 130 WASHNGTON STREET,3' FLOOR
T F-L (978) 745-9595
FAX(978) 740-98"
KIN
tBERLEY DRISCOLL
MAYOR DIRECTOR
ST.PiERRE
DIRECTOR OF PLBLIC PROPERTY/BCILDLNG CONWISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The
debris
ywill be transported by:
(name of hauler)
The debris will be disposed of in :
(name of facility)
j o, te , AW -
address of facility)
l r •��
signature of permit applicant
'date
dcbrisalTAx:
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