9 RUSSELL - BUILDING INSPECTION t -7 (
r of Massachusetts
41SP) �a t mg�lations and Standards CITY OF
LEM
Massachusetts State Building Code, 780 CMR SAMar
77pp�� pp QQ Revised MarZ011
Building Per1Y11t�A�p'iican To Constttuct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
_ Building Permit Number: Date Ap red:
(�1 4u, � 3 is/46
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 P e Address 1.2 Assessors Map &Parcel Numbers
Ili L la Is-this an accepted street?yes_✓ no Map Number Parcel Number
Itl— 1.3 Zoning Information. 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
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. Owner of Recor / fi
6ICK", V, kjPjz�C � )C V�'� 0! y l
ame(Print) City,State,ZIP
...w W-ft Nmjfi;n) s 13RO-9.
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Budding❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify:
Brief Description of Proposed WorV:
-in Vff-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 16, 0�/ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �j, W� ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES p
5.1 Con stru 'on Supervisor Li PA be
License(CSL) ~7G 9F' 7 /7 a017
I Ia'•�,"y�L U nq(ASS License Number 0 Expiration Date
N.am/e 5ff 7CSL Holder I"l/�IJ Q
!'/D / ,t rr /� List CSL Type(see below)
No. treet T Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/To ,S te,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
A" I Solid Fuel Burning Appliances
r Insulation
Telephone Email address aol. nim D Demolition
5.2 Registered Home prov ment Contractor(HIC) /Re'l` be
335/_ ay 0/
IY•V 741 HIC Regi
stration Number Expira'on Date
C Compaq e or C
o. Stre t r I Email address
Ct /T wn,State,ZIVTel hone
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
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 pplication is true d accurate to the best of my knowledge and understanding.
Print er's or Authorized Agent's Ame(5kctronic 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. oe v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemenVattics,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"