8 LARCHMONT RD - BUILDING INSPECTION The Cotiinumwealth of Massachusetts l Y llt
t` Board of Building Rego lilt[Otis and Standards I \11`Vll'll' \I Il 1
y Massachusetts State Building Code. 781) ('!SIR, 7"' edition
Building Permit Application To ('onstruct. Repair. Retlll\ale Or Ih•molisli ❑
One- o; T+ro-1 irmih Dtrrllir)y
This Section For Ot'ticial Use Only
Building Pcrmil Number: Date Applied:
Slunalure: 4t. "L Y�. ----- —� r�0---- -- - - - ----- .- -- -�
Bu 1 ng omnn"I"n.•i/ Itisil or of Buildings Date
SECTION 1: SITE INFORAL\TION -
LI Property Address 1 2 \+essors \Iap & Parcel Numbers
Liz-Cr� - -
iJ sc ether
i13 Zoninglrf::rmation• J�, t.4 IT:=r=ryGimcn:iv.,,:
Zoning District Propnsed Use _I Lo+ a I+y lii F•outuge tip l --.__.
r1.5 Building Setbacks (f )
T
j Front Yard Site Yards Rear Yard
! Required t�Pro%ided Requited Provide Required Pr"uJeJ
l --_ —_--
1.6 Water Supply: 1M.G.L c. 0, y 5i', 17 Flood 'Zone Information: LR ew'age Disposal System:
Z.one: _ Outside F! od Zone'' I \lunicipal pyOn site disposal sv.tem ❑
Puhlie Private❑ Check if yesy
SECTION ?: PROPERTY OWNERSHIP'
2.1 Owner of Record:
\.0 .• !Pnntt Address for Service: '?
; J1�'I .•111 'fl'ltphU e
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
—_
Ala.-: C tr v r. ,>:'tng Building Owner Oe.upwd Rep .irsu) AnerauoNs) ❑�.\JJiCnn ❑
Dzmolnu)n Bldg. ❑ _ Numbe:of Units T Pthcr ❑ S.,
e l i tf l esc;ipnon of P +.pose ' -JrjL� '--F-L�
SECTION J: ESTIMATED CONSTRUCTION COSTS —
Est:mated Costs: Of cial Use Only
Item tI_abor;md Materials))
Budding r7D ^ I. Building Permit Fee: i_-._ Indicate how lec is dclernoneJ:
❑ Standard City/Town Appbcahon Fee
'_. Electrical Y ❑ 'rota) Project Cost' (Vern G) a multiplier --_ s _
i. Flushing S 1 Other Fees:
4. .Nlechanic:d (HVAC) 3 ----
5. Mechanical 1Fiie ----------
Su l remnm) T�aul All Fees:
Q Cheek No. Check Amount _ _Cash :\mount—
b Total Project Co,t: S 0 -a .p '� 0 Paid in Full ❑ Outst:mJine Balance Doc:__- ----
SECTION 5: C'ONSTRUCTION SF.RV,ICES
5.1 Licensed Coiistruction Supervisor(CSI.)
I_icrn.e Numher li�pir.aum [Isle
S.0 ur tit CS I.- IIuIJrr
I.u( C'SI_ f%pe(gee helow I
\JJnro> I v C Descrl +lion
( 111rc+trIr0.`J 11 lU :i.I91U(ll. I'I
R Restricted l&2 F.unlls Dwclhlle
SI_n:uurr %I \Lixvus Unls ._
RC i%cifflu
fcleph"lle id 11.111_1.
iF K.'�IJrni.J SuIIJ Purl ISul ul n_`\ ++Ilan.'; bnl.il l.11n nl
D ReaJeullal Oc•luohtum
1
5.2 Registered Home Improvement Contractor (111C)
Ii IC Company Name or IlIC Registrant Name Reguuauon Nuluher
Address
F.rporalion Date
Signature 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 io poolde
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
1, as Owner of the subject property herebv
authorize to act on my behalf, in all nutters
relative to woo k authorized by this building permit application.
i
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, 177 ,, as Owner or Authorized Agent hereby declare
that thtQais tme and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
FnntFnnt Nnm . -
I
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of era ) --j
NOTES:
I. An Owner who obtains a building permit to do his/her own work or an owner who hires ;m unreg(stercd clmtra.lor
(not registered in the Home Improvement Contractor (HIC) Program), will rtot have access to meat bin at ion
program or guaranty fund under M.G.L. c. 142A. Other important inhumation on the HIC Program and
Construction Supervisor Licensing (C'SL) can be found in 780 CN1R Regulations I IO.R6 and 110 R5. respecnscly.
' When substantial work is planned, provide the information below: "
Total flours area..Sy. Ft.I (including garage. finished basement/amrs. Jerks or porehi
Gross living area tSq. Ft.) Habitable room count
Number of fireplaces Number of hedroums
Number of hmhrooms Number of hAtiha(hs
Type of heating system _ ---- Number of decks/ Potc hes ---
Type of cooling system
Z. .'Toed Project Square Footage- may be substituted for -rota) Project cost" __
rr
ti
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
w•n��nut�•�
I30wAA9UM41OM S W=*SAuaM,M. ASAcHum IS 01970
To-978L73S-9S"* FAx 978-7469W
HOMEOWNER LICENSE EXE.MMON
Please Print
Date 4��
Job Location <-P BAR C.41 iA 44 i44,gZ
Horne Owner Address
Home Owner Telephone
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER ,
Person(s)who owns a parcel of land on which Waite resides or intends to reside,on
which there is, or is intended to be,a one or two family dwelling, attached or detached ,
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner•'certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR 5
See other side for state code /
L
., >. CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
g�'IIVK vi
.,r. r:ir: .ia --
\I \\\i V.,..,)NS IiUJ—J T
Construction Debris Disposal Affidavit
(required li)r all demolition and renovation work)
In accordance %�itlt the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of h1GL c 40, S 54;
Building Permit it _ is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 1 I- S 150A.
The debris will be transported by:
Ou a' 'flume of hauler)
I lie debris will be disposed of in
(nun ullaclhty)
laddress u(I�cilily) 1(�1t�
� 1 {
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