6 LARCHMONT RD - BUILDING INSPECTION (2) r, yJ
7 The Commonwealth of Massachusetts
Board of Building Regulations and Standards cl FY OF
Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Our-or Two-Fantily DwellhksK
This Section Fo f i ial Use Only/
;Building Permit Number: Date Applied•ding 011icial(Print Nwne) SgteSECTION l: SITE INFORNIATIOoperty Address: 1.2 Assessors Map& Parcel Numbers
this an accepted street?yes_ no Map Plumber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.I.c.JU,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood-Lune? Municipal❑ On site dispwal system ❑
Check fifes❑
SECTION2: PROPERT/YOWNERSHIP'
.1 omen of Recor J y�
N;un (Print) City,S - . .IP
(l vT — 1{6% 6 f.�
Nu.and Street 'relephone Entail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repatrs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Cos :
Labor21ite,',sals) Official Use Only
I. Building SI. Building Permit Fee: S Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
i. Plumbing S �. Other Fees: S
4. .Mechanical 111\':\C) S
5. \lechanicol (Fire S
Suttrassion) Total A l l Fees:S_ ------ —. _.-..--
Check No. _Check Amount: Cash Anwunt:
Total Project Cost 5 ❑ Paid in Full ❑Outstanding Balance Due: -
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
Lietnx Number_______._ lispiralinn Uate R
N;une ol'C'SI. Iluldcr ------- --------
List CSL l-ypc(Ste below)
No. and Street - -- -- 'type Description
[I PC
(Buildings up to 35,000 cu. Il.)
_ _ R Rextricted I&2 Family Dw g
ellin
C'itclfuwn.State.ZIP hi Masonry
RC Rooting C'osnrin
WS Window and Siding
SF Solid Fuel Iluming,lppliances
I Insulation
'I'cic hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number Expiration Date
I IIC Company Name or I IIC Registrant Name
No.and Street Email address
City/Town,State,ZIP "rele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 .......... O 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) Date
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the information
con coed in this application Xtrue and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized, mit's Name(F.ectrmic Signature) Datc
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 ILol have access to the arbitration
program or guaranty fund under.M.G.L. c. 1 42A.Other important information on the HIC Program can be found at
ww w n t,,. rs o ,i Information on the Construction Supervisor License can be found at k%�,ni.ais o� dp,
'+ When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement attics,decks or porch)
Gross It\ing area(sq. 11.) - Habitable room count
Number of Iireplaccs `umber of bedrooms
Number of bathrooms Number of half'halts
l)lie of heating system _ -- - -. Number of decks, porches.
'f 1)pe ol'couling S\Stem Enclosed Opus
3. -focal Project Square Footage"may he Substituted for'?oud Project Cost"
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