8 1-2 LARCHMONT - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
g u.Massachusetts State Building Cute, 780 C'MR, 7 edition OF SALEM
Rrvisrr1YAV rn•
Building P ' Application To Construct.
21
Repair, Renovate Or Demolish a /. _'fNAY
one. r Two-Family Dwellinx
is Section For Official Use Only
Building Permit N be : Date Applied: (�
AV
Signature: /�
to ding Cummissi r Inspector of Buildings fate tt
SECTION 1:SITE INFORMATION
I.I�rogerry d� dress 1.2 Assessors Map& Parcel Numbers
l Z
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq 11) Frontage(11)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal stem O
Check if es0 'y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(,Print) Address ror Service:
Signature Telephone
SECTION 3: DESCRIPTION OR PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied Repairs(s) O 1 Alteration(s) O 1 Addition O
Demolition O Accessory Bldg. (3 Number of Unib Other O Specify:
rief Description of P posed Work': O 2.S
xFVS-C G c
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials 011lrld Use Only
I. Building S 1. Building Permit Fee: S - Indicate how fee is determined:
1. Electrical S ❑Standard City/Town Application Fee
O Total Project Cost(Item 6)x multiplier x
3. Plumbing I S 2. Other Fen: S
4. Mechanical (fIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
J 6. Total Project Cost: S /, Oo Check No. _Check Amount: Cash Amount:
J` , VU O Paid in Full O Outstanding Balance Due:
a
SECTIONS: CONSTRUCTION SERVICES
a
5.1 Licensed Construction
'tSupervisor(CSL) 06396',
I.iccnsc Number Expiration IYate
Naune ul'Ctil.• I lulder Lisl CSL Type Isee below)
3 CO S' f I)escriplion
:\Jdnss U tlnresuicted I un to IS,o00 Cu.Ft.
R Restricted IR2 Farm Ihvellin
Siynalwe --7 M M' Onl
'RC Residential Routine Covering
1"clephume w5 Residential window and Siding
SF Resiskmiat Solid Fuel Bumin A lianec Inslallmlun
D Residential Demolition
3.3 ReredHo 6lmpro%ment Contractor(HIC) 4NL/gr
1 IC Company N Cor 111C�Registrant Name Registration Number
Add /JJ —9�S'7S7 Expiration Due
ress_
Signs urc Tclephute
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL f ZSC(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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
9ionsture ofowner Date
\ SECTION 7b: 1OWNERr OR AUTHORIZED AGENT DECLARATION
1, ) \G.\n VV a wd �Tf — ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
J(\ Print Name
Signature of Owner or Authorized Agent Due
Si under the aim and rwhies of '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. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and 1 10.R5,respectively.
? When substanlial work is planned,provide the int'ormalion below:
Total tloan area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
). -Total Project Square Footage" may be substituted for"TOal Project Cost"