8 LARCHMONT RD - BUILDING INSPECTION (2) 1
The Commonwealth of Massachusetts
/ a Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I Date ppli
/XW /3
Building Official(Print Name) Si Date
SECTION 1: RMATION
1.1 Property ddress•/L 1.2 Assessors Map&Parcel Numbers
L_A-fG IYIO(`FI = P e'oq
Lla Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(ft)
1.5 Building Setbacks(ft)
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:
Public3„ Private❑ Zone: _ Outside Flood Zone? Municipal'6�On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re rd-
»f/ '/
No.and Street Telephone Elmlil Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ yRepmrs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Unitsher ❑ Specify:
Brief Description of Proposed Worhz: C✓i— (; ! - rat r✓ cJi✓ �+ S S
®1� i1� ���rc (rrCtR WfI IJFtiGI NCv✓
e../ . �i 4.. NLAr Sl s�fro<K, �t`
o fe i -nr CTIG % t urS
SECTION 4:V TIM61TD CONSTRUCTION CO TS:
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ / 000 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ p U ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ Z Sa G 2. Other Fees: $
4.Mechanical (HVAC) $ r,/ A List:
5.Mechanical (Fire $ N/�Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 40 ❑Paid in Full ❑Outstanding Balance Due:
VVf
SECTION 5: CONSTRUCTION SERVICES
5.1. Construction Supervisor
License(CSL) CS /OS 7lU /( 30 1.3
b2dcu � License Number Expiration Date
Name of CSL Holder (i
List CSL Type(see below)
U[ Type Description
No.and Street
2 p U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5 22 Regytsstered H/q�r/ate Improvement Contractor(HIC) l F/0 3 I
J��� �" sue^/ HIC Registration Number Expiration ate
r Z 3 me//! am'e�or Registrant Name Q /c 5�/ ^ ,v�C
No.and Stree Ef d� ('-Email address �t
4 we- L q O��Sa `//Y— S oa-77
Ci /Town, State,ZIP Telephone
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 Own r of the sub'ect property,hereby authorize wd Q �lI'v 2 l D -5-
to ad o y be)i0f,' 1 all matters relative to work authorized by this building permit application.
/ 2� �3
Print er's Name(fifectranic Signature) 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
cont ' int s lication is true and accurate to the best of my knowledge and understanding.
`� -
Print er's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/des
2. When substantial work is planned,provide the information below:
Total floor 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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"