5 LARKIN LN - BUILDING INSPECTION The Commonwealth of Massachusetts
k Board of Building Regulations and Standards Town of
000111111
Massachusetts State Building Code, 780 CMR, Ta edition
l 'w� Building Dept
;Building Permit Application To Construct, Repair. Renovate Or DemolisJa
One- or Two-Family Dwelling
This Sec n For O cial Use Only
Building Permit Numbertz
ate Applied:
Budding Commissioner/Ins for of Bui Date
SECTION 1: SITE INFORMATION
1.1 Property Address: Sn I£H 1.2 Assessors Map& Parcel Numbers
,j J-ArL,i(/r✓ �.RNC I /
1.]a 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 fl) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
N/A $ ! 1 /5 T-
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Fiood Zo ?
Public l� Private ❑ Check if es❑ Municipal Von site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow er'of Record
TEA M C�rfll< IoS S �Aai</ v �atiE SAfrJ MA
Name rint) /) n/ Address for Service:
N.:-1./'./��-6/u.(/l"C— 9 7k— 7 Y 5'-- 77 3 0
S' n are - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction I Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ ',Number of Units Other ,$ Specify: Cr1'2a EN .S{rp
Brief Description of Proposed Work':. �s
SNSTA/ GAR bE� E R - A r7l[�TE !O b x /y t x
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S ( 70, 1. Building Permit Fee: S Indicate how fee is determined:
_ ❑Standard City/Town Application Fee
2. Electrical S 0, ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S D. 2. Other Fees: S
4. .Mechanical (HVAC) S p, — List:
S. .Mechanical (Fire $ Q Total All Fees: S
suppression)
,�. Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S 70, 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N.4roe of CSL- Hylder List CSL Type lwc bclowj
L
T, I Descn non
Address U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature ..Yl Nlasonry Only
RC Rcsrdenua! Roofing Covering
Telephone WS ResidentaWindow and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Si nature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
Jaa
,as Owner or Authorized Agent hereby declare
ents and information on the foregoing application are true and accurate, to the best of my knowledge and
n //
nC%,qh O S - 91
wner or Authorized Agentthe sins and enalties of toNOTES:
r 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 1 have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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 li
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage" may he substituted for 'Total Project Cost'
CITY OF S. M
PUBLIC PROPERTY
DEPARTMENT
Nu�oraL"DaOUX
MAVM 130 WA,9uNGTON SMEW•SALM MAssACMSCM 01970
71L r..2•745-9S"• F.%X 978-740.9&4
HOMEOWNER LICENSE EXEMPTION
Plesae Pritat
Date 7/9 a 00 y
Job Locadota S F 521c/N I+ANt / 51916-1 1"M 0090
Home Owner Address I'Alrx IN JLArN5 St4/E r! HQ O/y70
Home Owner Telephone 97&- 9 3 0
Present Mailing Addrw r 1,9 rz t,� k n, !E S AL E M /-/r9 0/9 70
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be,a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING I1NS OR
See other side for state code