9 LARKIN LN - TBA-15-315 Z 5 Ic l l
` The Commonwealth of Massachusetts RECEIVE
Cluj
Board of Building Regulations and StandarASPECTIONAL S RV AL TT EM
1 n Massachusetts State Building Code,780 CMR Revised Mar 2011
U I Building Permit Application To Construct, Repair, Renovate 13
One-or Two-Fnrnily Dwelling
This Section For Official Use.Only
Building Perrtiit Number: Date Applied:
Building Official(Print Name). Signature - - Date
I SECTION 1:SITE INFORMATION'
1.1 P operty AJdress: 1.2 Assessors Map&Parcel Numbers
I.I a Is this an accepted street?yes no hlap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required - Provided Required Provided Required Provided
E
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public❑ Private Cl Check if esO P
SECTION2: PROPERTYOWNERSHM'
NN jrc(Print) City,State,ZIP
9 Lar-K \ LeAo'g — ����Z 5 3
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied O Repairs(:) O Alteration(s) O Addition ❑
Demolition O Accessory Bldg.❑ NumberofUnits_ Other Cl Specify:
Brief Description of Proposed Work-: Pr L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
0 Standard CitylTown Application Fee
2. Electrical S p Total Project Cost'(Item 6)x multiplier
3. Plumbing S P 9ther Fees: $
4. IN ech:mical (fIVAC) S List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
6. 'total Project Cost: S Z�Q(� ❑Paid in Full 13 Outstanding Balance Due:
I
r�
SECTION5: CONSTRUCTION SERVICES y
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name ofCSL Holder t
list CSL'fype(see below)
No.and Street Type Description
U I Unrestricted(Buildings tip to 35,000 cu. It.
R I Restricted I&2 Family Dwelling
City/Town,Stale,"LIP M Mason
RC I Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone E&nail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP Telephone
SECTION 6: WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L:e.15Z.§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
I,as Owner of the subject property,hereby authorize
t9 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:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in s applicat is true and accurate to the best of my knowledge and understanding.
Print Owner's or Au i rized Agen rate(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
www mass t:ov'oca Information on the Construction Supervisor License can be Found at www.mss� .
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) N (including garage, finished basementlattics,decks or porch)
Gross living area(sq.R.) Habitable room coon
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Typeofcoolingsystem Enclosed- Open
1. "Total Project Square Footage"may be substituted for,,Total Project Cost"
A • v ;C0.
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET,3"DFLOOR
TEL. (978)745-9595
FAX(978)740-9846
KINMERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date ZZ ((]9 �R Zal 11// p
Job Location I %r LAY10 SGI.a✓ n lM� Q � I—�o Home Owner Address 1 LA(Ic t✓% IG,,4 . . )o him, m A 01 1-4-0
Present Mailing AddressI
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 that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE �9
APPROVAL OF BUILDING INSPECTOR