51 LARCHMONT RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
1 Massachu Revised Mar State Building Code, 730 CNIR SALEMdMar
2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section;For Offi*T11se Only
Building Permit Number: ' Dat, Applied:;
Building Official(Print Name) Signature Date.- -
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Y/ LQrAr"04i k04�
l.la Is this an accepted street? yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) 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: 1.3 Sewage Disposal System:
Zone: C Outside Flood
Public n�e.9
�� Private❑ Zo
Municipal if yes)�Y unicipal On site disposal system ❑
., . .... , ..
SECTION 2:, PROPERTY OWNERSHIP'
2.1 Owner of Record:
C4f Lrnn(? /e.n , M)V 0)ei70
Name( r-- intP ) City, State,ZIP
s/ ,Lg/c�i�ronf c� y78- 7V :HV Cim&-'rle7�r�IyG7roo. 60A7
No.and Street Telephone Email Ad rest
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': f<1en7PdP1 full 6 /-/7 or7 S .co,-? oor,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item 1. Official Use Only,.
Labor and Materials
I. Building S ODU 1. Building Permit Fee S IndicSte how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical S v2 ODD ❑Total Piolect Cost' (Item.b)x multiplier x
3. Plumbing S S O00 2 Other Fees: S ,J
1 Mechanical (I-IVAC) S List.
5. Mechanical (Fire $
Su > cession Total All Fees: .S .
Check No. Check Amount: Cash Amount:
6 Total Project Cost: S JSQUo ❑ Paid in Full 0 Outstanding Balanco Due:
SECTION 5: CONSTRUCTION SERVICES ,
5.1 Comrstructiort Supervisor License(CSL) C6 v
Vr License Number E. irauon Date
Name of CSL ►�loldcr� v
n rr List CSL Type(see below)
1 601-17lG1) R04 C! Type Description
No. and Street
��"" y� UfiRoofing
ricted(Buildings u to 35,000 cu. ft.)
6e.f.,9Vef f 1;w 0/ la2.3 Rted 1&2 FamilyDwelling
Citylrown,State, ZIP NIr
RCCuvering
WSw and Siding
SF Solid Fuel Burning Appliances
y78_77#Sa�7 �Y���397-&a0�co, [ Insulation
I'elz hone Email address D Demolition
5.2 Registered Horne Improvement Contractor(I11C) /5-Zj7��
I�omes�eac� Fro espc rel 41-C IRC Registration Number Erplr.tionDate
HIC C rn an Numz or IIIC Re atraut Nmne
GormG� /Goad �i//397YCV'q'o1 Coh,
No. and Street Email address
�t�✓ens /rJf� o/9�' �i7�-775'-�5 ao7
City/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 Owner of the subject property, hereby authorize H6/hPS}P�c1 E� PP�iJ�1�LC/or V,, (66?,26jl
to act on my behalf, in all matters relative to work authorized by this building permit applica on.
6;w-X e4 17,-0ft /i b- /S, ''?O/3
Print Owwter's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
JLJLIPS�Pycf En1�E��6i1P1 �L��/AQ n /eLOL, �� �� / O -3
Print Owner's or�Authorizcd Agent's Name Signature) 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. I42A. Other important information on the HIC Program can be found at
www.nnus.,,ov/'oca Information on the Construction Supervisor License can be found at%v%Vw.massaov:d
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 tirzplaccs Number of bedrooms
Number of bathrooms Number of halubaths
fype of heating system ----- _ Number of decks/porches--_--
I)'pe of cooling system-.. —— -- Enclosed---- __Opcn
3 "Total I u>jact Squire I'ootuge may be substituted tor'`rutA Projcct Cost"
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards T Construction C Suptn isor
License:CS-082402 3
DAVID P GE1�lE '1'
127 STA '
BME��'
Y1qA19
1"'13 Expiration -
Commissioner - 031M612014
' !� Ottitt 61�00390��!nAt190310��1(e�018�h0� O� -
- HOME IMPROVEMENT CONTRACTOR
- Registration: ,154755 Type;
I Expiration: 4l32013 Partnership
_t H STEAD EN 1
WILLIAM LOWD. -
6 GORMAN RD.
DANVERS,MA 01923 Onderseertrary
4 j �
CITY OF S:UE.L1, AXSSACHUSETTS
v BUILDING DEPARTNWUNT
120 WASHIINGTON STREET, 3ie FLOOR
TFL (978) 745-9595
Rue(978) 740-9846
KI\fBERLFY DRISCOL
�1s4YOR THOF(AS ST.FIERRS
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COSL%IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ( Please Print Le ibly
N:iinc(BusiiioWr//nimtio``N U� eP
lndividual): om rL P4C/
L/JT✓/Q` f Ps LL�
Address: b &,or-M4/I dPaa j
City/State/Zip:A9 . MA, .23 Phone✓E:__�/7�— 774/—,j�07
Are you an employer?Check the appropriate boss 'ryps of project(required):
1.0 I am a employer with 4. 0 1 am a general contractor and 1
eytployees(flall and/or part-time).• have hired the sub-contractors6. ❑New construction
2.El I am a sole proprietor or partner• listed on the attached.sheet t y. remodeling
ship and have no employees These sub-contractors have S. (] Demolition
working for me in any capacity. workers'comp. Insurance. q, 0 Building addition
(No workers'camp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. e. 152.$1(4),and we have no 12.0 Roof repairs
insurance required.) t employees.LNo workers' 13.0 Other,
comp.insurance required.)
•Any appikuat dos Owks box rl must alws gill out the section below showing their workers'mmpdnrad m un pulley inruratlon.
'I hnneuwm"who,ubmir this a0davit indieating they am doing all work and these him outside cammcron must submit a new anldavit indicating such
°Gunmctors that cheek this box must anached an adidutwl shoat showing the name of the sable ntnctars and their workers'comp.put icy infetmadoo.
1 um an employer that is providing workers'cotmprnradon lusaranee for my employees Below is thr pollcy and Job slfe
information.
Insurance Company Name:
Policy U or Sclf•ins. Lie. tl: Expiration Date:
Job Site Address:5-/ 1—arc rW,7 l ko4cJ City/State/zip: J-i1C9/20
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration dato}
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Be advfxed that a copy Of this statement may be forwarded to the Ofrice of
Invustigwiutts of doe DIA for insurance coverage verification
1 do hereby certify under the pulps wrd penulrles of per/ury that the btfar tudem provided ubuvr is true and correct
lure: 41J Data: re-4 . fs and 3
slot e+• g7d?- 775'-Sa07
I011icral use wdy. Donor write in t/ds arer4 robe conrpleled by city ur town n/Jlelud
City oe Town: _____ Pcrmit/Licctne X ____ j
Issulag Authorily (circle one):
I. Buurd of Ileuleh 2.Building Departinent I.Cilytrown Clerk 4. Electrical fnspector 5. Plumbing Inspector
b.Other
Cuntaell'crson: -.. . - __._. _ PAonati•
pcc �
r
-� CITY OF S<U.Elt, tiLkSSACHUSETTS
Bt.ILDL\'G DEP-Aft-M&NT
�. 130 %V--%SHLYGTON STREET, 3' FLOOR
TEL (978) 745-9595
KIMBERI EY DRISCOLL FAX(978) 740-9846
NLWOR T1-1O.%w ST.P1ERRg
DI.QECTOR OF PLBLIC PROPERTY/BLUj:)DjG COtptISSIONER
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 111.5
Debris, and the provisions of NfGL 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
111, S 150A.
The debris will be transported by::
E, 7//. �U�, k.. //P lnlzl /�'nfJ .r C.
(name of hauler)
The debris will be disposed of in
Pe4LOJ ]lZful�PlS1(name of _
facility)
r address of facility)—
signature of permit applicant
6 S ao/3
date
aa, ;,tr d,x j
I�