9 LARKIN LN - BPA-12-851 I'hc C'onununsvcahh of Massaclutsctts
Board of Building Regulations and Standards CI I'1' OF
Massachusetts State Building Code. 7SO CNIR SALEM
Rd ri.wd.l Gill-2011
Building Permit Appliruion 'ro Construct. Repair. Renovate Or Demolish a
One- or rn n-P ionrls• Dn elfing
This Section For 01 iciol Use Only /
Building Permit Number: ate Applied: 41 _
Iluilding 0111cial(Print Wane) Signal Bale
SECTION 1:SITE INFOR N
.I Pro arty Address: 1.2 Assessu , lap& Parcel Number
L la Is this an accepted street?yes no Map Num 'r Purcel Number
t IJ Zoning information; 1:8 Properly Dlmenslons:
Zoning District PropaxJ(Iva Los Arco 04 11) Frontage(II)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Reyuircd Provided Required Provided Reyuircd Provided
1.61VwM apply:IM.G.I.e.40.§s4) 1.7 Flood Zone Informations I.8 Sewage 0 posal System:
14rbllc Private❑ Zone: _ Outside Flood%une7 Municipal®/On llta dllpUYYI Y)BlClm ❑
Chock if yes
SECTION2: PROPERTY OWNERSHIP'
2.1 Osr1ODDReo�aNumhe'W ,R cIAU-M MA- 015 �-d
Mane(Print) City.State.ZIP
k L gluki i AI.iG, 3
No.and Street relephune F.mail Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ E.risting Building❑ Owner-Occupied Repairsls) ❑ Alleratlon(s) ❑ 1 Addition (3
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify:
Brief Descrip of Proposed Work":
9U1Ll71Nrr AIF..J Z x 173 ' 'DL'r- rK) (2K O� 1/D�Si
SECTION J: ESTI.NIATED CONSTRUCTION COSTS
heat Estimated Costs: Olilclul Use Only
Labur mtd \laterialsl y
I. Building S 1. Building Permit Fee: S Indicate how f'ee is determined:
I '. S
❑Standard City?own Application Fee
lileclrical
❑Total Project Cost'l Item On multiplier
�. I'IumMng S ?• Other Fees: S-
J. \Ieclt. l ,II\ \('t S List:
utica .
\fachanic,d iFire ----
tilltlret5lUn) S rotal \II
('heck No. ( Iteck:\nnnuu: Ca,it \mount:
Tnlal Project Cllei: S 3 l�dU ❑ P.tid in Full 13 Outstanding lial.mce Duo:
SEC HON41: ( ONSMUcTiONSERVICES
5.1 ('otistructiultSulicr%i.ior License((Si.)
S 1. 1 loldcr Ist IV('4V lwkm)
Nu. .md Street
PC
It unrestriocJ(Ililildino 0 W 15-02()v2 It
R Rv.,1rid%:d 1&,2 F-imil Mwili"
Cirri town,State.LII'
%I Mamm
RC R,xifln Co%vrin
14's window.uid Sidin
SF solid Fuel Burning Apaiiinct:1
I Insululion
fete bona himil addrexi 0 Denuditiun
5.2 Registered Ilorne Improvement Contractor(HIC)
I IIC Relitar.1titni Nwntwr r\J11rL111W1 VA!
I IIC Compin) Name or IIIC HeSl.strunl Ninia
No. and Street Email address
Cio,/Town.State,ZIP relephone �I
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 153. J 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 ..........Q No...........C3
SECTION 7s: 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.
Print Owner's Nanic(Electronic Signuture) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By a a below, I hereby attest under the pains and penalties of perjury that all of the information
entering
my=app�wdlon)s true and accurate to the best of my knowledge and understanding.
contained 11
1!�-P* el
116 Owig.r*.i or Aw kiriicd Avin"Nalliv WNctroniv Slgnalumj Mto
NOTES:
1. An r—O%Nner who obtains Tbuilding permit to do his.her own %%ork,or an owner who hires an unregistered vuniraour
I o'J11ot registered in the Hunts Improvement Cuntrticturi HIC) Program),will jLL)JI'lavc access to the arbitration
program or guumnly fund under M.G.L.%:. 142A.01hur important inrormalion on the HIC Program can be found at
Information on the Construction Supervisor License can be found at%%%%,% ill
lien substantial wurk is planned, provide the iol'urinatiun below:
Total flour area(sq. ft.) finished basement attics,decks or purJii
Groii It\ingarea 154. 11.1 iijbitalih:rouin count
\ulibcroffireplaces Number ol'bedrooll's
\,umh%:r kit hathroomi Numhvr ol ImIt hall's
I peal heating S\sion porches
Sion
loi,il 1;tlkort: 1:001AV.C111A hc skibNtmavd liar l'otol Project 0'A"