9 LARCH AVE - BUILDING INSPECTION (2) N
The Cummonwcalth of Massachusetts
wn of
Board of Building Regulations and StandardsT
1/� 410100
Massachusetts State Budding Code. 780 CMR. 7'a editionept
Building Permit Application To Construct, Repair. Renovate Or Demo
One- or Tito-Fm iji Duelling
This Sectio or Official Use Only
Budding Permit N ber I Date Applied:
Signature:
Bwldin omm stoner/ ns t uddings Date
SE TION 1: SITE INFORMATION
1.1 Properly Addr s: 1.2 Assessors Map dt Parcel Numbers
1,Ia 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(54 A) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public CI Private O Cheek if es0
SECTION S: PROPERTY OWNERSHIP'
2.1 Owner'of Reeor }
Naanrie 1 int) Address for Service:
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction O Existing Building O Owner-Occupied arl Repairs(s) Alterations) O Addition O
Demolition O 1 Accessory Bldg.O Number of Units_ I Other O Specify:
Brief Description of Proposed Work: `
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building f I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
1 Electrical f ❑Total Project Cost(Item 6)x multiplier x
). Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) f List:
t Mechanical (Fire f Total All Fees: f
Suppression)
heck No. _Check Amount: Cash Amount:_
6 Total Project Cost f � dr-a . 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
� C Laenee Numh Eapir ion D e
Nwe of CSL H er List CSL Type(see helow) U
AJdress i Description
U Unrestricted(up to 35,000 Cu. Ft.
R Restricted 1ik2 Family Dwelhn
Signature M Masonry Only
RC Restdenttal flooring Covenn
Telephone VS
Revdennal Window and Siding
Sle I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Robftred H e Im rover t Contractor(Pic) //��`Z
>�
H mpap amor HI gistr t N — eguuauon Number
14
Addre / 1v
•apirati Date
Si elephone
S CTION . WORKERS'C ENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 Affidavit Attached? Yes .......... 0 No........... O
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: OWNEW OR AUTHORIZED AGENT DECLARATION
I, CS SPAY/ A ri as Owner or Authorized Agent hereby declare
that the statements ad information on thelf&rqjoing application are true and accurate,to the best of my knowledge and
behalf.
L
Pr �
Fe �
Si of Ow of or Au homed Agent Date a--f�
i ed dunder t Bins and nalties of u
NOTES:
I. An Owner who obtains a building pentril to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will ff&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 IO.R6 and I IO.R5, respectively.
2. When substantial work is planned, provide the information below
Total floors area(Sq. Ft.) (including garage, finished basemenVattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/ porches
Ty pe of cooling system Enclosed Open
1 "Total Pro)ect Square Footage"may he substituted for 'Total Protect Cost"
_. . _ CITY OF SALEM �.
PUBLIC PROPRERTY
DEPARTMENT
nl\Ilt� NI P.'i!•R hl.�'i I.
\L`•l i qc 120 W.\il]IXGI ON STB LET #SAI r\t, htASI'M I It it I'I i J l'✓.
fcl:978 N."+-9iY$ 1'AX:978-7449846
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 It -._ 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
l 11. S 150A.
The debris will be transported by:
/ Oiamd/jdf hauler)
The debris will be disposed of in
`
(name of fac IIy)
(address of facility)
si ure of permit applic
ry
date
Ache ratTduc
_ CITY OF SM.E.`Is �L�SS.XCHUSEM
BL: DLYG DEPART\IE.NT
120 WASHINGTON STREET, 3m FLOOR
T L (978) 745-9595
F.tRx(978) 74119M
KINgBERIEY DRISCOLL
MAYOR hmobus ST.PrEm
DIRECTOR OFPLOLICPROPERTY/lIVI DLNGCOSMUSSIONER
Workers' Compensation Insurance AMdavit: guilders/Contractors/Electrieians/Plumbers
> > licant Information Plestem Print Legibly
Name(Busincv Orgatfratiom Indavtduaq:
Address:
Ciry/State/Zip: j; p L�iy�� 0Z9/,�)1'hone * 97�1 Shy Z4 a cZ
Are you fiployer'Cheek the appropriate boa: Type of project(required):
1. am a employer with,�_ 4. ❑ 1 am a general contractor and 1 6. ❑New constnrction
employees(full and/or pact-time).• have hired the subconnacmrs
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
ship and hove no employees These sub-contractors have g. ❑ Demolition
working for mein any capacity. workers'comp.insurance. 9• ❑Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] ot7icen have eaereised their
3.❑ 1 am a homeowner doing all work right oreaemption per MOL 11.0 Plumbing repairs or additions
myself.[Na workers'comp. c- 152.)1(4).and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.] ]I I
'Any applicam this shacks boa II muss alm on eat the serum below showing their workees'campanry(un pahiey in&nmarlote
'I Lmwowaen who submit this aflldavb indicating they an,doing all work and thin him amide mn means mtut suhmb a new a tldavis indhadng rate►
l.maavion that cheek this boa mud attached an additival,ehst thawing the tune of On wb onuae on iced thak wodner'comp,peliey inrum&dm,
l am an employer that Is providing workers'comprnmllen lmatrronee jar my employees Below/s the pellay and Job slta
iftjarmation d
Insurance Company Name: ' —
Policy Nor Self-ins. Lic. N: 6 54/4y46 7o��j�� Jr=�' �Fpiration Date:
Job Sire Address: q' VP(�i �P Ciry/StawiZip:
%ttach a copy of the workers'compensation policy declaration page(showingthe 1 policy sunhat and expiration dab).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Ile advised that a copy of this statement maybe rorwarded to the Office of
Insvcsngationa ul'the DIA for insurance coverage veritication.
/da hers a• 'y uadn the pains un shirt ojpe ury at the information provided above is true and correct
Win•r t r ' Doc : _ D
Phu 4: �
iDfluial use mdy. Do not write its this area,to be completed by city or town w/jiciuj
I
Ciry or fuwn: __ Pcrmit/l.lccnre N__.
Issuing.Xuchuray (circle acne): -
1. Ituard of Ilrullh 2. Building Department 3. City/town Clerk 4. Fln:trical Inspector 5. Plumbing Inspector
6. Other -
Contact Person: _ -_. _.. Phone#: