11 LARCHMONT RD - BUILDING INSPECTION i
Massachusetts
The Cummumvealth of
Board ul'Building Regulations and Standards (-"Ty
I , Massachusetts State Building Code. 780 CMR, T"edition ()F SALEM
� Rrvirrv/Jurrurgr
Iluilding Permit Application To Construct. Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OMci n
Building Permit Number: D Applied:
Signature:
Ruilding Commissioned In or of Buil ngs
SECT N 1:SITE 1A4421MATION
1.1 Pro rty Address: i7 Assessors Map A Parcel Numbers
1.I o Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sal 11) Frontage 111)
1.5 Building Setbacks(R)
From Yard Sidi Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§Se) 1.7 Flood Zoe*lnformmilon: I.8 Sewage Disposal System:
Public fd Private O Zone _ Lamide Flood�2°n°7 Municipal IrOn site disposal system O
SECTION 2: PROPERTYOWNERSNIV
21 Own rrotRaeo
Name(Print) r Address for Service:
x
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check oil time apply)
New Construction O Existing Building Owner-Occupied O Repairs(s) R� Altention(s) � Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proposed Work': fp
Ay-
� Rb2lL .A L C � C kQ
r S /
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: O(Ilelal Use Only
Labor and Materials
I. Building S J/� / I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S O Standard City/Town Application Fee
O Total Project Cost(Item 6)x multiplier x
J. Plumbing S 2. Other Fen: S
J. Mechanical (11VAC) S List:_
S. Mechanical (Fire
Suppression) S Total All Fen:S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S , O Paid in Full O Outstanding Balance Out:
r
SECTION !: CONSTRUCTION SERVICES
5.1 -L/k eased Construclloo Supervisor(CSL) ,O.I
C , ) P),,l„//,A Z I.&— I.iecnse Numb r F% into n imic
Nardi ul CSL- I holder ti I.ist CSL Type(see below) o.14, L
f 11hescri Ian
Wdmaa U Unrestricted 10 33.000 Cu.Ft.
R Restricted l&2 Faiiiihi Dwellin
M M (hit
Sign:t�w-rey!
1 /Y, 931, tLV RC Residential Roulin Covers n
WS Residential Window and Sidin
fcicphune SF Residential Solid Full Burning Appliance Installmiun
D Residential Detnolgttan
5.2 Registered Hostile Into rvvement Contractor(HIC) /Q6-7Z
Aaw �d✓L(AG'fdiLS Registration bcr
111 ' y Nao or HI 'Re tatralT a�G G 6 .� /Z
Addre %/�`,;3�7�e�/ Expinstiolt Dale
Sigrow 'dephurte
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L a Ill./ 2SC(6))
Workers Compensation Insurance atTtdavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the lssumcg of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 74: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.
Si ureofOwner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 1 1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of )wner 0/Authori 1 Date
Si under the aina andpenalli f 'u
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 0g have access to the arbitration
program or guaranty fund under M.G.L.c. 1 42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 7110 CMR Regulations I IO.R6 and I IO.R3,respectively.
2. When substantial work is planned,provide the information below:
Total floors area ISq. 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
). "Total Project Square Footage'may he substituted f'or"Tolal Project Cost"