4 LARCHMONT RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
4 .U�e. Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALENI
Revised Mar 201/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number Date Applied:
y I
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
LI Property Address: 1.2 Assessors Map& Parcel Numbers
I.I a Is thisthis an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arca(sq I'0 Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rzar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(ibL(i.L C.d0,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1�Owner'off
Numc I'ri � Record:
s_ ( "C C, c S1C' QiS� JM
( ) City.State,ZIP
No. and Succt Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ ration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify:
Brief Description of Proposed Work: _
SECTION 4: ESTLMA TED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ ��. C(-' I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (I IVAC) $ List:
5. Mechanical (Fire Suppression) $ Total All Fees: $
Check No. Check Amount: Cash Amount:
G. Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due: --
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) y7Ti7/J
0+4 :1�, �i.� License Number Expiration Date
Name of CSL Holder
List CSL Typc(see below)
No.an I Street Description
Unrestricted(Buildings u2 to 35.000 cu. ft.)
City/Town,Slate,GIP
U R Restricted 1&2 Fainily Dwelling
M Nfasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulxlion
Telephone Email address D Demolition
5� istere/d�llome�provem�en�Lontr�c (IIIC) a Iff2—
HIC Registration/Number Expiration Date
HIC Compn Name or HICa}cgistr, t Name
�vv�
No.at Sirect �
Q�lv t/��vi>?j .mad address
City/Town,State,ZIP /� Tele hone
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 .......... No...........❑
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.
Print Owner's Name(Electronic Signature) Uute
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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 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.naass.�,ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
2. When substantial work is planned, provide the information below:
Total Floor area(sq. R.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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. `"Folal Project Square Footage"may be substituted for"Total Project Cost"