22 LARCHMONT RD - BUILDING INSPECTION (2) V� The Commonwealth of Massachusetts
000 i,1 Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Rerlsvd.l hir 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Otte-or Two-Fomilr Drrellin
Phis Section For 01ii Use {I
Building Permit Number: Da Apppp"liic'ddr0 _
Building Official(Print N,une) Signature �� /�
SECTION 1: SITE INFORNIATPN.�
1.1 J;rMrty Address: 1.2 Assessors NI Parcel Numbers
I.la Is this an accepted street?yes_ no Mop Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Pmntage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal ❑ On site disposal s):stem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
£/r z�S.T ti f3-4�T lghn 1(oS�r n t se) Jon /IV 007
Jl� Nmne(Print) C'it Slatc.ZIP
�� L/a/G)1 of vnT /tom ���•
Nu.and Street "relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
.New Construction ❑ 1 Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ FAlteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: -
Brief Description of Proposed Work-:
(Zr ivNo✓e ►� n lG 9 fl s 5- t g tl )
rlo
SECTION a: ESTINIATED CONSTRUCTION COSTS
Rein Estimated Costs: Official Use Only
I Labor and N laterials) y
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City,'Town Application Fee
❑Total Project Cost(Item 6)s multiplier It _
7. Plumbing S ?, Other Fees: S
q. Mechanical I W.W) S List:,_-_
\� S. .�ICL'IIanlCal (Fire
x I Su t tression) S Total All Fees: 5----------- ._....
JJ �� Check No. _Check :\mount: -----—Cash Antuunt
Total Project Cost: S Il S—Ro— __ --
❑Paid in Full ❑Outstanding Bal:mce Doc:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Number ----- Ifspirwion D;uc
List CSI-l)pe(see below)
No. and Street -- — - - T)Pe Description
tl l Inrestricted(Buildings up to 35,000 cu. 11.)
R Restricted Iit2 Fantil Deellin
C'ityi form.State.ZIP AI Nfasonry
RC Rtwlin g Covering
- W'S Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
'fee hone ('.mail address D Demolition
5.2 Registered Home Improvement Contractor(H IC)
I IIC Registration Nundwr Expiration Date
I IIC Company Name or I IIC Registrant Name
No.and Street Email address
City/Town.State.ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
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
contain d in this application is true and accurate to the best of my knowledge and understanding.
L (3enS-0^ 9'' 1-l\
I'ril 0ahner4 or Authorized agent's Name(17ectrunic.Signature) Dale
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\I.G.L.c. 1 q2A.Other important information on the HIC Program can be found at
ttlstt m;t>s 4oc oc,i Information on the Construction Supervisor License can be found at k%)kmas� dil,
2. When substantial work is planned. provide the information below:
Total Floor area(sq. R.) 1 including garage. finished basemerWattics.decks or porch)
Gross living area(sq. tl.) _ _ Habitable room count
Number of lireplaces-__----- --------_.- __-- Numberofbedroonts
Number of bathrooms Number of half hatlhs
1)pcufheatings)stem _ _.._ Number of decks, porches
fh Ile ot'1:001616 syslcnl 1'.I1clo,ed _Open
1. "1'taal Project Square Footage"play be Substituted lix"Total Project Cost-
�� Offire�fC`oasume�r`R�1�eiis&BUsine��liegu anon.
HOME IMPROVEMENT CONTRACTOR TY�
Registration 118825 .
Expiration 412612013 .Private Corporatic
q ROOFINGrSERVICES Ilsl iE
DAVID BENSON
58 RPULASKI ST
PEABODY,MA 01960
Undersecretary
i
Nlussachusetts- Department of Public Safct%
Board of Building Re};ulations and Standards
Construction Supervisor License
License: CS 54528
Restricted to: 00
DAVID J BENSON
1DONEGALLN
DANVERS, MA 01923
�L iJ /.LJE Expiration: 1 112 0/2 01 1
('onnni.airmrr. Trp: B369
. 1 . - •1-• .. - r
0
CITY OF S.U-&Nf, %Ws.A a-iUSE-rrS
BULDLYG DEPAR-MENT
110 W.ISHLYGTON STRM, 3"FLOOR
ILL (978) 74S-9595
FAX(978) 740.98"
KiSBEP EY DR=OLL
,MAYOR THo.+L11 ST.Pt8RRld
DIRECTOR OF PLBLIC PROPERTY/BCILDLNG CONMISSIOYER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A_
The debris will be transported by:
�1l�en- Tr9� snDrT�►'7:.�-L
(name of h uler)
The debris will be disposed of in
-)ice.
(name off facility)
//l✓��lPi't✓�
(address of facility)
signature of per it applicant
r'l - 1"
date
I.M1nvl(•bw
ACORD, CERTIFICATE OF LIABILITY INSURANCE OATS17
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PRODUt%R SOD.792-0251 FAX 781.261-2099 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC - Main ONLYANOCONFER$NO RIGHTS UPON THE CEWnFICATE
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