22 LARCHMONT ST - BUILDING INSPECTION IThe Commonwealth of Massachusetts
l I OF
Board of Building Regulations and Standards CITY M
WMassachusetts State Building Code,780 CMR S
I Revised dMar Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section cial Use Only
Building Permit N r: e Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
o�Property Ad�d�re�ss ^ 1.2 Assessors Map&Parcel Numbers
1.l a Is this an accepted street?yes no FF Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) 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: -
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.17 of Re o d:
CIa (�cn� 4)� �� Slate, AA cm- c>
Name(Print) City,State,ZIP
')a LArrA„%w 'S - 0i-)W- c l-19 -570'- `�cCL,2@ c.reA�VreI%ecAAL.
Cc A-
No.and Street - Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ F Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Amory Bldg. ❑ Number of Units Other A Specify:G--�JK 014^45 a,n
Brief Description of Proposed Work :
'�.�s�-c�\b��rrw.
SECTION4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs Official UseOnly
Ld3or and Materials
1. Building $ kc) ana 1. BuildirtgPermitFee $ Indicate how fee is determined:
❑Standard CitylrownApplication Fee
2. Electrical $
13, (oDD ❑Total Project Coaa(Item 6)xmultiplier x
3.Plumbing $ 2. Other Fees $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees $
Check No. Check Amount: CashAmount:'
6.Total Project Cost: $ 11 pad in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/fown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone - Email address D Demolition
5.2 Registered Nome Improvement Contractor(HIC)
'��l enDn au HIC Registration Number Expiration Date
IC Co pany N^�e pr Hl Reg t-
Name
No.ano Street I Email address
C�ov\Jer, Ln
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 e-Ie n 64 Paa er ��.,Sle—s
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner'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 m knowledge and understanding.
vJrge���� Qaac! S s2 s - Le of
tI
Print Owner's or Authorized Agent's Name Electronic Signature) Date
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
vvvvw.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"
Richard J Testa P.E.
P.O.Box 5536
Wayland,Massachusetts 01778
Phone: (508)561-1260
Fax:(617)969-0628
ritestair(a2Qmail.com
December 14,2010
Leo Pamode
Independent Power Systems
Customer ID#A042
Project:
Brandt Residence
22 Larchmont Street
Salem,MA
Dear Leo,
I have reviewed the Independent Power Systems calculations and check the additional loads
associated with the new Solar Panel layout.
I have done independent checks of the existing structure and I have determined that the existing
framing will meet the requirements of the 7t4 Edition of the Massachusetts State Building Code.
If you have any questions,please feel free to call me at 508-561-1260
Sin el o ,
OFAAgs�
D J. ym
ST JR.
Richard J.Testa Jr.P.E. RAL
y o.araes o a
FSS�ONAL EN�'�
ET-0's UMOTHOFHOUBER00F.
b7RM As®tr=
Ir8' 10'Ar
h7MFRR(fYP.) 1w RWEB0AR0
N
r
bq
TT
X
F
BEARING WALL PVPM'E18 PV PANEL WMT(7YP,) .
NOTE:
RooFBHESTHwonNoexwcnes PV PANEL LAYOUT PLAN
NOr BNOWN FORLIA )NORMALTO R FBNRFACE)
BCPLE:1 yC4`
A�A%.
Independent Power Systems Bradt Residence De. 124s10 sn W. to We
1601 Lee HIII Dr.Unit 24 22 Larchmont St.
Boulder,CO 803045602 - Salem MA B)DNAtE•'`
Phone:303.443-0115 DrenN ice .
Fax:303-443.2173 S1 .00
' e�mofl�w'Am mrmaeoumwm�x ramarM° 8pN 1'M' EWNwBry 6Hmp
PV MJWLE
ZryR MaoulE 9ACNGHEEr
SLNF E4F°OT
�@ 0
S
P413PTUNWr
s•B mmN wI
OATEYnAB M
STRUMRAL SCREWS
ASPHALTSIONGLES
2X6 Jo
aWFeNFATHW°
9EARPIG L
M
JR.
RAL a
PV PANEL MOUNT DETAIL .SRISS c
acnerovb FGIBTEP�
n A
' `88/ONALE�G
Independent Power Systems Bradt Residence Ga. uasro snPmNo.
1501 Lee Hill Dr.Unit 24 22 La:ohmont St sham o..nn
Boulder,CO 80304-5602 Salem MA
Phone:303-443+0'115 °w"0f JCB
Fax:303-443-2173 S1.01
c�iemim,sNa oesamrw.ew�aw� gab 1y1' E ul 8Mq
CITY OF S.U.&M, N'LxsSACHUSETTS
• BUMMING DEPARI-.%M\T
• 130 WASHLNGTON STREET, 3' FLOOR
TEL (978) 745-9595
Fex(978) 740-91M
K1�t$FRr F.Y DRISCOLL
MAYOR THoma ST.PmRRa
DTRECiOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
date
debriQlUm
CITY OF SMENi, !NLkSSACHLSETTS
BUUMLNG DEP+RT%ENT
• 120 WASHiNGTON STREET,Sao FLOOR
TEL. (971) 745-9595
FAX(978) 740-9846
KI.%fBERLEY DRISCOLL
MAYOR THomu ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO%L%IMIO.iER
Workers' Compensation insurance Affldavit: Builders/Contractors/Electricians/Plumbet'a
Applicant Information `` Please Print Leeibly
Name(Busine Organi:anion/tndividuW)-iy ,D,,, us P J, gRC
Address: es )A L
City/State/Zip ?J�� , /�.�. (�I�Is Phone ig_ 910129
Are you an employer?Check the appropriate box: Type of project(required):
1.,A 1 am a employer with _57 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
officers have exercised their I0.❑Electrical repairs or additions
required.]
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself(No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers'
comp. insurance required.] 13.�00ter a✓QA✓eQS a�
Any appliers that chesics box#1 most also fill out the section below showing their w•mken'compensation policy infonse im,
t l fameawncrs who submit this affidavit indicting they are doing all work and than hire outside tmraaQmrs most submit anew affidavit indicating sueh
;Contractors that check this box must attached an additional sheet showing the name of the sub-contactors and their workers'wrap.policy intermarket.
l am an employer that is providing workers'compensadon Insurance for my employees. Below Is the policy and job s(te
information. //''
Insurance Company Name: 2t�f-t� Lrvv0
Policy N or Scif-ins.Liic..#: IOC a_ A(A ` �a 30 — oct Expiration Date:
lob Site Address: oa Xnew LArra� 0: City/State/Zip: C)
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date}
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or once year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
!do hereby certify a der,t/� artd penalties of perjury that the information provided above is true and correct
l �t %/� Dare:Sn.na ttre�/
0 �
Phone ; 9 k gsk �D*�!�
Official use only. Do not write in this area,to be completed by city or town ofjiaiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of lfealth 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ _ Phone#:
' Acoftp CERTIFICATE OF LIABILITY INSURANCE ° 1
THIS CERTIFFCATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE ODES NOT AMEND,EXTEND OR
sorsberg �a .wa" �eaY ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
3575 S. 8hasmaa at. -
Em9lewood CO 80123' INSURERSAFFORDINGCOVERAGE NAIL#
phoaec 303-762-2717
tea: Sm=lah Group
Iadepeadeat rower syar�e T..^ oswac
3oa3Pacio Properties LLC mom
. Oo01 Xe 3 Ai110 #23-24
awe
COVERAGES _
SIff1�06OimwYYM1SLLw®w3OM�w1¢w�66wLmTME091N®x.Y®IwTIdPoRWe � vAE
/J!'IflEdW�OR.1aNOREa�IwS�ANPm011elmPlw31IY11111EHb.'IlC19mt NwMwl1�4f449u0�
WYYaRMITEt®aW GN WMG®0YT&WIY65Q�1.'6�IORR0710/d1.1IH190REs619�
NTImSPC11�AElYw3ID�WwTXINEB�II�B.IYIwOM� -
NIlIX8i6w6 IVifFYwa➢D9 LLm!
Wnw:04� 1� m� GwIC y
- ovaom a
ma®vnm¢YAI.IWMY -
�mwo®s®u s
mvauerte Fxl o[me .
vesawr.axwamn s
� s
- vamrmsmmoraan
mn�.awrr.masvee-
wm uc
ern2v m
. allomme�m� - �mreemrt a
a4.m+a
nevaum
' mmrouun a .
ataw®ums �w®1
sa®wm+mo% _
mmrmner y
wawa puamw+o
rd➢ipfE®Nllm .
' - enacmwvw y _
unoaa.-e.�
uwmwcamwn - _ rw.wc s
aaenwe
aarwm wmaur. aw s
smtacwvaws
�mu1aLLY p��E s
atop aeoavra a
a
8 mama
sw�sas +� a
C wmm AC 4632630-00 (M) 09/15/10 09/01/11 e+- '�" 500000
m ¢yow�_usm�arff 3500000
seaman
. Fy�•�asr�mr s Won-
CERTIFICATE
asw�wm�mamm .
mwt
a=mr�ama.uxamwwaomB�vamoaovmsa+wm�.amur�vm�
HOLDER - CANCELLATION
1'Ommm ama.ormraamYemae+�swaaE+wm®awe�mraavm®
wseam®cra6wrenmw®t�sau.mmmn 10 maser
- xommramm�w�nwwawmmraustwsgmowmmwwnu
vaaszwowmwxavwm.oasan�wm�rawo®i.wn®nsa�
c
®ACORD CORPORATION IM
ACORD 25(2001N8I
- — Office of Consumer Affairs and Business Regulation
10 Park Plaza —Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 167101
;r Type: Corporation
Expiration: 8/11/2012 Tr# 201698
INDEPENDENT POWER SYSTEIV9
--=—
LEO PATNODE ,+,� \ -r + '
4645 N. BROADWAY A4
BOULDER CO 80304 —
IIpdate Address and return card.Mark reason for change.
"�- F] Address Renewal n Employment n Lost Card
' ACORD CERTIFICATE OF LIABILITY INSURANCE OPa snw1 05
THIS CERUFICATE IS MUED AS A p1ATTER INFOp99AnON
momaa ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CEtTIRCATE DOES NOT AMEND,OITE'U7 OR
Forsberg P ge=Rn ComD�Y ALTER THE COVERAGE AFFORDED Bl(THE POUdL°S BELOW.
3575 S. Sherman St. - -
Emglewo d 00 80113 INSURERS AFFORDING COVERAGE NAIC#
Phone: 303-762-1717
pm�u: SUEioh
Gwom
amaze -- '
rndeyendemt Eover sys Imo wsmRc
8oO f�girOP=ti923
L5 —26 mmia¢
Boulder CO 80300 aeaawie
COVERAGES
neamxffswemmurmusc®®amp¢�a®am®mx�ammaewmmaemmrw�'mxr�o�m«rnama�umea
urea[mmammaa¢�waaa:am®wivaaaami!iTmaam�mw®rv+m � m@meow
wY16�W4Tm�w¢wb/A�mw&aa,cdDa��1m9a6rmaun¢�eNtumommndtamaa�
am�msarr�ameuocsme¢uawo¢e®+�mwamam �y� encrtms� umn
mm rmewamveax seunamaa< acre mim�mCwaaaa�aa a
asaa3mat�auwama meamasw
mmewmsmo�w a
eumuam rx 1
waam¢aawwam s
�nawmamm
mmwm-wam>sao s '
rewrta�wsr ms -
wm. me
owar
�st¢asumr a
avmamaEamaom {aamrq
amaum
. wa¢avumr s '
aumm�auma ptrpemp
ammo®nnm
eomramea - s
.m®aurm ma�mem
amawaonamw
eaarmwaaaw a
�mr.maam
ammom+-eaaca®¢ a
ma0111� GI[t m
mmw�wYB
_ unamo aummmr. am a
�e s
ms�nuua®or ara�emae a
ovum �mavwvam a -
a
mme�m a
aeemw °�
8 mo'� 8 as
09/15/10 09/01/11 m�mm.a¢mert a 500000
C WC C692630-00 O0•) $500000
amavoae+ ayaamaw-awamor s 500000
oa.aa>,atrma.
sentwmmmmaw
m®
�myswau�nmumi��®mB�wov�owmmi>��
CERTffICATE HOLDERTomrmm - CANCELLATION
¢umm.ormaa.am®aau�m`moo�mammmreawmm.
ammmmmm�wa®�am.eamwwamama 10 amammw+
' amoum�monrsrexummea®mrem�sxmuamomimmemwu
ommazsmmmammmaouw®m+wanmmumumommaasam�am
aaa -
>mwa®
._ ®ACORD CORPORATION 1988
ACORD 25(2MMM