53 LARCHMONT RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR, 7`" edition ReOvF SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
T s Secfion"For'Offioial'Use Omy
Building Permit Number: Date Applied:
Signature: (�
. _Building Commissioner pe r.o£Buildmgsf, ,Date: -
SECTION'li FORMAT ON. :
1.1 Pro a Address: 1.2 Assessors Map&Parcel Numbers
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: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
,SECTIONPROPjtTY^OWNERSHIP',
2.1 O nerr of Record: Qu /
, ame [ Address for Service: G r
�Z � - 7Y5�
Sign re Telephone
SECTION;3:DESCRIPTH)N OF PROPOS,ED'WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
Q S v Al i/ fc�
SECTION 4: EST,IMATED'CONSTRUCTION'COSTS
Estimated Costs: "
Item Labor and Materials " ' Official Use Only
- 1.Building $ 'A. Building Permit Fee. $ Indicate how fee is determined:
2.Electrical $ .❑Standard 7City/Town Application Fee -
❑TotalrProlect Cost'(Item 6)-x multiplier _ x
3.Plumbing $ 2.,Other Fees. $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees:$
Y� TT Check No Check Amount: Cash Amount:
6.Total Project Cost: $ fJ ❑paid in Full ❑ Outstanding Balance.Due:
`,•,t „ SECTIONS bCONSTRUCTIONSER�ICES,• , ;;
5.1 Licensed Construction Supervisor(CSL)
M (C a e L IA-r-6c . License Number Expiration Date
Name of CSL-Holder (/
� List CSL Type(see below)
/�S Vdl yUC � � I1 P S
�'DeScri tion
Address—� + � � '< T `•_'' ' • -
�� ,� � U Unrestricted u to 35,000 Cu.Ft.,�`k
—�—� R Restricted I&2 Family Dwelling
Signature` C� M Masonry Only
7 3 `'•S' 7 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regtstere Hgy�e Improvement Contra for HIC)
L( A-e �i1—1� L L_ L %D (i
HIC Co Name or HIC Reg' nt me Registration Number
Address 1 c C
�sD
Expiration Date
Signature / Telephone
SECTION 6:WORKERS'COMPENSATION IN$URANCEAFFIDAVIT,(M.G.L.c. 152. g.25C(6))
.n
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 AUTHORIZATIOMTO,BE'COMPLET,EIS WHEN'
OWNER'S AGENT OR-CONTRACTOR,,APPLIES:FORBUILDING PERMIT.
1, as Owner of the subject property hereby
authorize to act on my behalf, in all matters-
77,
relative to work au or ed y thig building permit application.
' am
Si nature of Owner - Date 2Z
SECTION 7b: OWNERr.;UR AUTHORIZED'AGENT DECLARATION
I, 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.
L l
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
,. :. .. _
., . .`. 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 not have access to the arbitration
program or guaranty fund antler M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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"