5 LARCHMONT RD - BUILDING INSPECTION (2) .,. ';► ' The Commonwealth of Massachusetts
^� • I Department of Public Safety
\Iasichu.ctt.Slate Building Code 1780 C\IR)Seventh Edition
City of Salem
Building Permit Application for any Buildinlj other than a I-or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION l: LOCATION(Please indicate Block 0 and Lot 0 for locations for which a street address is not available)
5 "t 5 LARCOMOUT• FQ SALOW 0)9')0
.\o.and Street Cih• /Town Zip Code Name of Building fit applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check ail that apply in the two rows below
Existing Building❑ 1 Repair❑ Alteration ❑ Addition D Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy D 1 Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: RCIWV � OLU f20ea/�it/�' t
��6>tA!
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s):
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4 D A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional f-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile D R: Residential R-10 R-2❑ R-3❑ R-4❑
5: Storage SI ❑ S-2 ❑ U: Utility Cl Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ HA ❑ 111) ❑ IIIA ❑ 111110 IV VA ❑ VB ❑
1/ • SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Su I Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
PP Y° Licenwd DispoNil Site❑
Public ❑ C heck if uuhide Plood Lonr❑ Indicate municipal ❑ �� trench will not be
required Cl or trench ar,paciA•:
I ncaty❑ or utdcnfite Zone: ur un air ay.trm❑ permit ix enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: liaon. Pry,,:
\ol Applicable❑ i.SlruRtov wuhm aupurt appn uch area.' I. their re% Vv, Completed.'
n l',m�cnl lu Itudd rncov'd ❑ 1'u.Cl or No❑ Ye.Cl \o Cl
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I:'.iiw�n.d (�alr: _ L.a•Crnupl.c Tt pe al Lund nii lion: l)caipant Load per I loor:
llw, Ihr building coni.un.in Sprinkler?caem.': SpecialStipulauan,
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner rn n
RlVJJ n_n_A_9_y .5 LAO-CEMD41-2 SAL M /T 0070
Name(Print) No.and Street City/Town Lip
Properly Oaoner Contact Information:nn7pp-_7—���/�7Y y/�5-T��
Title Telephone No.(business) Telephone No. Icell) e-mail address
If applicable, the properly owner hereby authorizes
Name Street Address Cily/Town State Zip
to act on the +ro perky owner's behalf, in all matters ndative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is lass than 75,WU cu.It.of enclo W s pace and/or 1101 under Construction Control then check here D and stop Section IU.I)
10.1 Registered Professional Responsible for Construction Control
EAU,. �i lV n &E:LO U-,53L- 0 IF I I CrW51-iVoM LO�nrs% I d 8 353
Name(Registrant) Telephone No. a-mail address Registration Number
:K rZA/AilA4z!a1? f?c/Ienyia yYJ�I. 6 ��960 8-2f3- 171
Strerl Address Cityy/Tow .State Zip Discipline Expiration Date
10.2 General Contractor
� nt-s c0lvst u�r�0(I) LLC..
Company mr:
AU�I'1 on 1V9L6
Name of Per wn Respmsible fur Construction License No. and Type if Applicable
6TF_nlxlf�t/6s G-/`gf
Street Address _ Cit /Town / State Zip �!
2£-.3ZC-�b .� F�IJSTi r/ �Gd 4� {+ISN.CO -E
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS' OMPEIVSATION QVSURANCE AFFlDAVIT(M.G.L.c.152.§ 2SC(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building $ s Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=5
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=S (contact mu icipalily)
5. Mechanical (Other) b Enclose check payable to r
6.Tom Cost S (contact municipality)and write c eck number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
6v 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.
19ease print and sign name Title clef hone No. 1 .Ile
Street :\ddre.s Citc/Town State
Municipal Inspector to fill out this section upon application approval: J �� 7 I� /�
\'ame I).ue