7 LARCH AVE - BUILDING INSPECTION (4) AVM ajar
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 71h edition OF SALEM
J1 1,�sr Revised Jmruary
/� LJ Building Permit Application To Construct,Repair, Renovate Or Demolish a /. 2008
I One-or Two-Family Dwelling
This Section For Official Use only
Building Permit Number•. al, p lie
Signature: (/ -
Building Commissioner/In pector of Buildings)a\VDate
SECTION OftEXANFORMATION
I.1 Propel Address: 1.2 Assessors Map& Parcel Numbers
LA2C.h A✓e _
1.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
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) 1.1 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwner'of Record:
cry Roacharz r) LA." 4✓2,
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
RP rvv_9✓2_ SIN-, �e_ roar 4 n STrE\1 /lL w
T
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
I. Building s I. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing I $ 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S //�,JO— 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ;1E.—scu—nse
i r)-
DA V Z `den s� Number f•xpimtion Date
Name of CSL•I lolder Type(see below) V
nne p L LAn e— P/ Uescri Lion
AJdre' llntestricteJ u to 35.000 Cu.Ft.Restricted IB2 Famil Dwelling
Signature M M• Dnl
q 1 S- %L3 RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 1 B ; d
PI 5 2 1 S .u-y,Ce-
HIC C mpany N to Registration Number
T 1'eA wM
Add f. s31,7�(3 Expiration Date
Signature "relephone
SEC ION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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...........Cl
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.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I bly: Z Ile/I szh as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accur , o e st of my knowledge and
behal f
Print Name 11
Signature ofqo
r Authorized Agent Date
Si ed undeins and Enalties of 'u
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&of have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.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'
L
CITY OF SM EN19 NLASSACHUSETTS
BLamm DumIT1ENT
120 WASHNGTON STIM, Ye FLOOR
T'EL (978)74-9S95
FAx(978) 1a496"
Kl..(BiEnEV DRlSCOLL TiOKUST. ML"
y(AYOt
D1sJ:croa of R et.tc psopcRTtr/Kt2.Dac coNMnsstoNElt
Wurkers' Compensstlos Insurance AlTldevit: Builders/ContractorWElectrielsns/Plumbers
annllcant Informatlon Plesse Pr(nt Ledbhr
Vatne tguarw+a0rgaaotMieoalonkv,duall: r� S�Pn 2J5�, .� S2r�.ct� l..-�
Address:
City/State/zip: I C >a- �I y 6Phone A.
�l 7r J 3 I- 7 6 6�
F..22'
e ye"a employer!Check the appropslote boss Type of project(regtdred):
�1 am a cmployar with�_ 4. ❑ nt I a a general connector and 1 d, ❑Now construction
cmployees(Adl Miller pan-time).• have hired the A&Co&war n
I am a sale proprietor ar partner listed an rM assehd sheet t 1• ❑Remodaling
.hip and have no ampbyets These sub-comnetars hew s. ❑Demolition
%working ror me in any capaany. %VWkens'comp instuaooa. 9. ❑Building addition
INo workers'comp insurance S. ❑ We ase a eorpondm and is
rcquiraLl
ofters haw eaaseised their 10.❑Electrical repairs or additions
).❑ 1 am a homeowner doing all work riae orexeimptios per MOL 11.❑1Mumbing repairs or additions
myself.(No waken'comp. C. I5Z f 1(41 and we hsva no 12.❑Roof repairs
insurance required.] ► croploycea.LNo teachers' I).❑016ar
comp insurance requised.J
-Any apptrraM the dtaeba bw rl MM oho AN Use Ihm scrim 11111M*AWi y tbdr r, . 'muses edsta Whey inArowidea,
'I6wwawnwe who rib"ads Admit inalcol"iMy an Jai o all rub ad des bb wwide asseOsa moot wbell a now,anlbvb i^11mia'a ,L
f.+nra+an ohms cbwa die two~3ns1W as 3"wrwl Am ' i da raw ar 16/sirsrnawo ra ddt rwaw'rs7.twliayr inA•waaeM
/use as
rwOMyrr rAwt bPnrJ/GR wwAris'cowpawmrlre/waurwawfor Myoayfoyuetl SNaur 6 rAi pNle�ate/�tr1 r/i
informs&^ ��
Inwrance Company Vamei &42 r� 6/
Pnlicy 4 or Self•ins.Lie.M: Expiration Dab: /
Job Site Addrasa: '7 L' " It—L CityJStasiZip S,9 t 4-4 U L
►hack a copy of#be workers'compoeea be policy doclorstlos pop(showing the policy asstres sai sspirsMos d1b)6
Failure to wart coverage a required undo Sectioa 25A o(MOL c. 172 can lead to the imposition oferiminai penalties of■
r one up to S 1,500.00 and/or one-year imprisonmoar ar wall as civil penalties is the farm of a STOP WORK ORDER and a Res
,tf up to 3270.0o a day against lha violator. Ile 241vira(11141 a COPY u(thia s,131a clam maybe rurwardcd to the 001eo of
Invcvugaliuns Myths n1A for insurance cavwage v%anticalioo.
1,10 hereby certify U;MJT rAoOwiwa ant Ornnhlea 0/0„/u07 that rA*inforwallow Onridd above is nvo and a wed
I)as: -d-7 - r o
P•
/)lf/rir/war wa/yL bd nor write is this area`to be a ornpletd by city ar teww n//trust
City or Irwin: _ Yermit/Lleense
Issuing.%whurny (circle une):
1. Ituard u(Ilrallb 1. Ruddlny I)cparrmeno ). ciiy/fora Clerk 4. fleclrical Inspector S. Plumbing Inrpeetol
6.thher
i L .nlacl Person: . _ Phone r'
CITY OF SALEM
PUBLIC PROPRERTY
�• DEPARTMENT
\I .n'N I.Q a.1N I,\L.,ir�l Mkl'T �5.111 f1, \IA.:a I11 V , •:1'I'.
Construction Debris Disposal A171davit
(required liar all demolition and rcnovatiun work)
In accordance with the sixth edition of the State building Cole, 790 CMR section 111.5
Debris, and the provisions of MGL c 40.S 54;
building Permit At 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
t 11. S 150A.
The debris will be transported by:
t names of hauler)
The debris will be disposed of in
&C� Lvw-,
(namrolacflly
taddrell of I'aeduy)
,1-ua1�nl•Iwn u,pphaaru
V -d-7 -la
dale