7 LARCHMONT RD - BUILDING INSPECTION � 1
�a --- The Cbnmmonsvealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 C NIR SALL\1
Reiiaed.lLn all
Building Permit Application To Construct, Repair, Renovate Or Demolish a
(hue-or Tu o-Fou,ils• Dn rllhuq
This Section For Official Use Old
Building Permit Number: Date Applied:
Building Otlicial(Print Marc) ig Signal Date-
SEW-ON I•SITE INFORMATION
1.1 Pro arty Address:/ Q� 1.2 Assessors Map& Parcel Numbers
I.la Is this an acre ted street? -es no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy 11) Frontage(It)
1.4 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood"Zone? Municipal O On site disposal s)stem ❑
Check if yes❑
{/ SECTION2. PROPERTY OWNERSHIP'
2.1 Ow�G Q R Ile-sty. e�- V/ to 7
Nwne(Print) City.Stale,ZIP
`72S'?*:5--53/R_
Nu.a5lreet relephune Emuil Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ I Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units / Other ❑ Specify:
Brief Description of Proposed Work-: e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use O1
(Labor a ad \laterialsl Only
1. Building Sr I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard Cily:Town Application Fee
❑Total Project Cost'(Item 6)x multiplier __ x
l !. Plumbing S '. Other Fees: S
4. Mcclianir,d III\'.\(') S List:
\Iechanica) (Fire ---------- - - ---_ . .. .
/ 0� ('heck No, _('heck :\mount: _ Cash \uunull:
I, Total Project Cost: i ❑ P;lid in Full 0 Outstanding Bal:uace Due:
t �
SEC 110N S: C'ONS'1'RUC TION SERVICES
5.1 (construction Supervisor License(C'SL) (C1 Ll�5J JO/
I icense Numhcr 1's'iral on Dale
N;une ol'l'SL I InlJer
list CSI. I)pe lscc
.I. Description
PC
No. anJ.Street
U 1 inrestrieleJ I ILIi1Jings uo to 75,Ut1U of 111
Q_/�0✓��� . _ R Ne.,,tricleJ 1 r2 P,unil bttcllin
Cnti fnw n,date.LIP SI Slaiun
RC' R'ndin Caccrin
_ K'S K'indosc;mJ SiJin
tiF Soli)Fuel ILvning AppIIallceY
a 1 Insuimiun
'I'cic hone P.ntail addresr D Demolition
5.2 Registered Home Im movement ntruclor(HIC)
I RC'Rcgutrnwn Nwnher spir,trill', Date
Nany m]]yy o�r III('Registrant Name
o. V-e-
N J Sueot f� Q� p a a �c+i�/�" Email address� nv�rs � L 02
City/Town. State,ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52. 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 7s: OWNER, UTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING P RMIT
I, as Owner of the subject property,hereby authorize ��f �� /L/ -erS
to act on y behalf, in 11 )totters relative to work authorized by this building permit application.
Print Ussner's Nw (Elecwnic Signut ) Date
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 0%%ner'e ar:\u tnrireJ,\gene's Nnnte(P.Ieclronte Signature) ala
NO I'ES:
F2.
i n Owner who obtains a building permit to do his,her own work,or an owner who hires in unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program), will nn have access to the arbitration
program or guaranty fund under\I.G.L.c. IJ?A. Other important information on the HIC Program can be tumid at
t'ts is m.l.. ��s . ..1 Information on the Construction Supervisor License can be found at t''s t' nl.t.:�n -It',
\Then substantial work is planned, provide the information below:
l lloor area(sy. fl.l ____,._I incuding garage, finished basementattics,decks or porch)
ss lit ing area uy. Il.l ---- Habitable room count
\umber oflircplaces \untherol'bedrooms - - - .
.\Imther of hathrounts . . _ . . \'umber Of half haths ..
Icy pc Of heating system _ - Nunther of Jecks, porches
pe,�1 eJVllllg iUle111 1�ndoYcJ Opelt
t. "I�11.11 I'raject Syuarc PnOtage- nt:q he sOhstituted tier"fatal Project Cost"