17 LARCHMONT RD - BUILDING INSPECTION CK ► 1 aO Il Z-
The Commonwealth of Massachusetts RECEDED
Board of Building Regulations and Standards INSPECT10Nh I SEFMrEQF
Massachusetts State Building e,780 CMR Cod SALEM
Revised Mar 1011
Building Permit Application To Construct,Repair,Renovate Or��noojhai A I I 5 b
One-or Two-Family Dwelling
This Qe,ti^^.For Official Use Only
Building Permit Number. Dat Applied. -
D
Building Official(Print Name) _ Signature Date
j SECTION 1:SITE INFORMATION
^V��1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Rd
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
rOwner
trict Proposed Use Lot Area(sq ft) Frontage(ft)
ing Setbacks(ft)
Front Yard Side Yards Rear Yard
d Provided Required Provided Required Provided
Supply: (M.G.L c.4Q§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal L9'On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
r`of RecoP_�r _ /T t City,State,ZIP
No.Id Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Regairs(sjiq Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Desert ption Proposed Work":
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item osts: Official Use Only
i55terials) Y
1.Building 1. Building Permit Fee:$ Indicate how feeds determined:
.JJe2.Electrical $ ❑Standard City/Town Application Fee
3.Plumbing $ ❑Total Project Cost'(Item 6)x multiplier x
2. t: Fees: $ Irv,
—�
4.Mechanical (HVAC) $ List: �
5.Mechanical (Fire
Su Suppression) $ Total All Fees:$
6. Total Project Cost: $/ Check No. Check Amount:' Cash Amount:
❑Paid in Full ❑Outstanding Balance Due:
µQ.tL-k�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Superviisoof License(CSL)
Ll� �/ Expiration
Name of CSL Holder cc List CSL Type(see below)
No.and Street Type. Description
U Unrestricted(Buildings up to 35,000 cu.ft.
[,Lt' Restricted 1&2 FamilyDwellin
City/fo tale,ZIP M Masonry
RC Roofiritz,Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I IInsulation
Telephone it address D Demolition
5.2 Registered Home Improvement Contractor(111C)
IC Registration umber Expiration Date
HIC Comp t r C Registrant Nam
No.and Street
Email address
Ci a 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 Owner of the subject property,hereby oie A�915er At1J P f �vhWn'? ky
to act on my behalf,in all matters relativ o w an oriz y this building permit appl cation.
eEv- neAi
I g�vo
Print Owner's Name(Electronic Si ate
za
SECTION 7 OWNER'O AU ORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain pplication is true and accurate to the best of my knowledge and understanding.
rint Owner's or jCuthlEzed A enfs lectronic Sig ) ate
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 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.aovioca Information on the Construction Supervisor License can be found at www.mass.uov/dV
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"
ZONING DISTRICT: R1
9f
At
iROD a i/
N/F No. 29422
KEVIN & DIANE O'CONNELL �� 4'°�'Re 4'- : li'l
19 LARCHMONT RD. A
PARCEL ID: 27-0519-0 ' e5 ti y� y Y )'� !
ci
5b0/ iv s 0.
'000 ,`
"I CERTIFY THAT THE NEW FOUNDATION IS
5 O. o,
N/F ,, LOCATED AS SHOWN. THIS PLAN WAS PREPARED
JEFREY JACKSON & 0p v.
ALUMINUMRY SIOED e FROM AN INSTRUMENT SURVEY."
ROSAMUND COMBS—BACHMANN ,o0• 0 � ��
16 LEE ST. LI �`
PARCEL ID: 27-0533-0 t.. �O RALPH W. REID P.L.S.
DEC( „..*
LOT 104% v03
GRAPHIC
ti� 5000±S.F. ,@ 20 o 10 SCALE 40
00
a.
\-s° \ di
CO,°p• NEW ,0O. ( IN FEET )
$ FOUNDAII. 1 inch - 20 ft
i. 0-
DAVID & CHELSEE SHEILS gti MATHEW THOMSON & SALEM , MAS SAC H U S ETTS
14 LEE ST. LAUREN RUSSELL
PARCEL ID: 27-0534-0 15 LARCHMONT RD. NEW FOUNDATION PLAN PREPARED FOR:
PARCEL ID: 27-0517-0 ER N EST V. D EMAI O III
17 LARCHMONT ROAD
II
N/F PARCEL ID: 27-0518-0
a JAMES COLLINS & REID LAND SURVEYORS
I ANDREA CANNELLA 365 CHATHAM STREET (Lys)
12 LEE ST. LYNN, MASSACHUSETTS
e PARCEL ID: 27-0535-0 PHONE #781-592-2660
a DEED REFERENCE: �tra*
S15-027A
BOOK 34198 PAGE 6
RWR/LTS DATE: DECEMBER 11 , 2019 SCALE: 1"=20'
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