3 LARCH RD - BUILDING INSPECTION *.
The Commonwealth of Massachusetts
UBoard of Building Regulations and Standards A
Massachusetts State Building Code, 780 CMR. T"edition Building Permit Apphcanon To Cunuct, Repair, Renovate Or Demolish Okmoftdwo
One. or Tsro, milt•Dwelling
This Section Por Official Use Only
Building Permit Num ':lioah li
Signature: 'T�/�/�
Building Commissioner/ nspector o Date
SECTIO 1 ITE INFORMATION
1.1 Propert ddress:� V 1.2 Assessors Map k Parcel Numbers
r Map Number Parcel Number
I.la Is this an accepted street'. yes no
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c. 40,S54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal System ❑
Public D Private D Check if es❑ P Y
SECTION 2: PROPERTY OWNERSHIP' /
2.1 Qwyer'of Reeoyd4n/6a. L✓i1/� .3 /�`,,c�
//� Addreu for Service:
Na (Print)
Signature Telepp om !�o
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building D Owner-Occupied D Repairs(s) D 1 Alteration(s) ❑ Addition ❑
Demolition CI 1 Accessory Bldg. 0 Number of Units_ Other ❑ Specify:
Brief Description of Propos� ork':
iY✓ d— KryC
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OITlelail Use Only
Item Labor and Materials
I. Building f 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard Ciry/Town Application Fee
2 Electrical S ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing S 2. Other Fees: S
4. .Mechanical (HVAC) S List:
S Mechanical (Fire S Total All Fees: S
Suppression)
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S e�p°O 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction S/upervisor(CSL) C-./p GC 2 C / G,
Lwen.e Nuumbbc E r .pI uuo Du le
Nypr SL Hplder J List L SL Type lace below)
Tvpt Dean lion
Addrcss�
� U Unrestricted(up to 35,000 Cu. Ft.
R I Restricted 1&2 Family Dwellin
., Masonry Only
RC Rcvdenual Roofin Covering
Telephone w5 Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 ) r Reg1 mip�yms�provem��ggt Coyyrrac�or(HIC) p'Y
� � IS,,WJ ( �?fp1ctl7b�I
HI om any yr HI Regisnant N e Registration Number
b - -.Cold
Add
X4taS'` �f�C...J Expiration Date
Signature Telephone
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........... 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize iDJl to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7__—F
b:OWNER'OR AUTHORIZED AGENT DECLARATION
ao-r 6Y $/' ,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. /w� C
Print Name
Signature of Owner or Authorized Age Date
(Sisined under the pains and penalties r 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 W 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 10 R6 and I 10 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 ISq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Tvpe of healing system Number of decks/ porches
Typeof cooling system Enclosed Open
1 "Total Pro)ect Square Fooiage" may he sub.muicd for 'Total Pro)cct Cast"
CITY OF S.U.Ea`I, AXSSACHi:SETI'S
SUILDING DEP.\RT\IEd1T
120 WASHINGTON STREET, 3'FLOOR
TFL (978) 745-9595
FAx(978) 740-9846
KIN
[BERIEY DRISCOLL --
►YOlt THOMAS ST.PMRM
DIRECTOR OF PLBLIC PROPERTY/BUILDING CONMUSSIONiER
Workers' Compensation Insurance AITtdavit: Builders/Contractors/Electrlcfans/Plumbers
A r licant Information Please Print Leeibly
Naine (Rusin 0r&tanirarion,ln svtdual): / Ge//LFvs
Address: 3/2 e4
City/Statc/Zip: Phone All. elf-= 3efz
\re y n so employer?Cheek fh ppropriate be:: Type of project(required):
67 I'a-
■employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the subcontacmrs
2.❑ 1 am a sole proprietor err partner- listed on the attached sheet : 7. ❑Remodeling
;hip:and have no employees Then subcontractors have S. ❑Demolition
workingrot me in an capacity. workers'comp.insurance.
Y P tY• 9. ❑Building addition
[No required.]
workers'comp. insurance S. ❑ We are a corhave
exercised
and its 10.0 Electrical repairs or additions
required.) otYtcers have exeroised their
3.❑ 1 am a homeowner doing all work right of exemption per MOL 1e1.0UPumbing repairs or additions
myself.(No workeri comp. c. 152,§1(4),and we have no 1repairs
insurance required.)t employees. (No workers' ) her
comp. insurance required.]
•Any applicant that chalu Dan rf mmW sew fin 01111119 action helot showing their work='cornpmntk n policy information.
r I Lvrwuwnaa who su6nmil this affidavit indicating their ate doing all work and then him outside coistlnQera trust submit a new affidavit indicating such.
:C.,ni murs that chick this Doss most anachd an addiliwd+lion showing Ow rums,of on sukeonsractore ud ow,wwkan'cwnp.policy inrormarise.
f am air employer that/s providlnR workers'rompensodon lntnronee for my emplayerx Bdow fr rho policy and fob sits,
informatiom
Insurance Company Name:
Policy Nor Self-ins. Lic.N: Expiration Date;
Job Site Address: City/StaWZip:
Attach a copy of the workers'compenisdan policy declaration page(showing the policy number and expiration dsto)6
Failure to secure coverage as required under Section 25A of MGL a. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonmento 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. lie advi•--d that a copy of this statement maybe forwarded to the Office of
.I it vcsu gat iunnoft he DIA for insurance coverage verification.
/do hereby certify under the pains and penaldes of perjury that the information provided above is true and carreet
,;wnjii urc: Date:
Phone 4:
Official use only. Os,not write in this area, to be completed by city or lawn official
City or Town: Pcrmibl.lccnu N
hsuing Authordy (circle une):
I. (luard of Ileanh 2. Building Department J. City/town Clerk 4. Electrical inspector 5. Plumbing Inspector
6. OI her
6nuact Person: - ___ __. Phone N:
� s
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I 11i qc - 11t)\Y.\il IONS MICT ��.\I I'\1, S1dtiiAt:I It il.I i�JI'L'l;
Tel:978J45 9395 PAX: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 It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting front
di
this work shall be sposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris wil I be transported by:
qJ /2 ys
(name of hauler)
The debris will be disposed of in
(name of facility)
taddress of facility)
O
signature of permit appli• t
9-/mac
ate
dc�n ralr due