9 LARCH AVE - BUILDING INSPECTION (3) [ t
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 780 CMR, Vh edition
,►t Bruised Junaary
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number• 42 Date Applied:
v Signature:
Building Commissioner/InspKturof Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
' L��l-I xy.�
I.la 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(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.do,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private[3 Zone:
if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2./ wnert of Record.,,
S�; 1 2 }6C'V-1 A' -e-
Name(Print) Address for Service:
1'7 251.5-05-
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': OP aeca
—t1� C2.,.,c�•k '3oAsd '5'91 eg vn.D tHil.l� ,•,•. bnar�5
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and
I. Building ( d M W I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard Cityrrown Application Fee
❑Total Project Cost (Item 6)x multiplier 1� xx 3. Plumbing S 2. Other Fees: S -
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S
suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
�' Lice Ise Number Expiration Date
Name of CSL-Ifolder List C'SL'rype tree below)
s 2a' S2 17� sF IY( � vlga- c14&�
Description
Address Unrestricted(up to 35,000 Cu.Ft.)
R Restricted IB2 Family Dwellin
Sil4yaturc M Masonry only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regbtered Hobme Improvement Contractor(HIC) 2 pq y Z
T T�� (�
tIIC Company Name or IIIC Registrunt Name Registration Number
<'.n-o s � nD Tc✓� � �c! I��? �t Sa-3 IZ��I� �--
AdJ
Expiration Date
Signature
SECTION 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 , 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.
Sianature of Owner Dale
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
�( la--. ,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.
Print Name
/U
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of '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. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I l0.R6 and 110.R5,respectively.
Z When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/arics,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
PUBLIC PROPRERTY
DEPARTMENT
I III: MI 11 "MIv .'•11
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l'FI:'/:1•!�S-•/ /S 1'.�!l:119•14YIM46
Construction Debris Disposal Affidavit
(required fur all demolition said renovation work)
In accordance with the sixth edition of the State Building Code, 730 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by::
I name of hauler)
The debris will be disposed of in
D.1e ram
p,:une u1Taclln"�—
InJJrcte ul Ix,luyl �;
.Ignature of Irernnt applicant
late
k4n..11 dti
CITY OF S.U.&A NLASSACHUSEM
0L•ILDLNG DEnATSIENT
120 WASHINGTON STREET, l'ROOR
TEL (978) 145.9599
FAx(978) 74498"
KiI.BEA EY DUWOLL 71410aW ST.PIRI AM
.UAYOR DIRECTOR OF PLaLIC PR0PERTY/2VMDNG CONL%OSSIONER
Workers' Compensatlon Insurance AllldeviC Builders/COntractors/Electric(ans/Plumben
antrllcant Inrnrmatlots Please PHnt Legibly
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Address: 45- 9-a5 f
Cily/Statdzip: Phone Al. CS2V) c/7 5- C-16/3/
Fam
Itsapbya!Check the appropriate boar Type orproiect(requires/}
ployer with 4. ❑ I am a general councem sad 1 a ❑Now consutsctios
es(fall and/or pan-time).• have hired the suhmontm sn
le pnprieer<or partner listed an rite attached slsnL t 1. Q Remodeling
haw o0 employee Those sub-cor nwwn have a. Q Demolition
rot ms in any capacity. rwrters'comp.inawanoe. 9. Q Oeilding;addition
krns comp insurance S. Owe are•eespaadas said is 10.❑Electrical repairs or additions
tequimL) adkos hew es nolstd their
).Q 1 am a homtmwner doing all wont ^lib of ettarnprion par MGL I I.Q Plumbing repairs or addWwn
myself.(No workers'comp C. I3Z#1(4),and we haw no 12.13 Roormpain
insurance required.) t cmpbyeoa LNo workers' I1.Q Other
comp insurance mqubeLi
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in�orwWlaa
Insurance Company Vame. /A/o Z[t-a-L",C -���S+-><L�7'•`��- Co •
Policy 4 or Self•ina. Lie.At: Tb U C'n I Z q� 1_ Eapiranion Darr 7l1 L /0
Job Site AdJnsr a2Y /Vo Moe 12 id City/StattvZip 4it�
.\track a copy of the cawksn'compauoWs pWey declarstle a pap(stowing the palky sumber and esplrselos dab)6
F;Iilun to sorwe coverage as required under Section 2JA of b1OL a 112 can lead to the imposition of criminal penalties are
line up to S 1,500.00 and/or one-yew imprisonatent,as well as civil penalties is tin rams of a STOP WORK ORDER and a flao
.tr up to S210.00 a day ugainst the violator. Ile adviwvl that a copy of this statement maybe rurwarded to the OlYlce of
inv"iillatruns orate nlA for insurance coveraes veritication.
/,Is hereby certify sendw tha pains and Pena/Iles e/perjuq their ties beforwetlea proeidad ubove is it"end C•arreea
';ICIIAtnre_ qurc 5 / { � U
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Forte 4, !q'?CJ� t-!71 �e��
O/JICial We enl)L Oo na write in'his Trace to be,VOMPlered by dtj or fe"'V efflaief
City or runn: errmit/I.Icenst e__
bruin! .\mhonty Icircle doe►:
I. ttuard u(llealtb 1. Aurldlnil Ocpariment 1. city/rowa Clerk 1. flectrica) Intprctor S. Plumbing lmpeetor
6. other
L•,ntact reason: _ _ -.. Phone: