12 RUSSELL - BUILDING INSPECTION 176
CL, CEIV SD T ommonwealthofMassachusetts
t?�' jIONAI uilding Regulations and Standards CITY OF
\ is/ ?r'PEC LEM
Massachusetts State Building Code,780 CMR SAMar
�`: -� �j Revised Mar 20I
JWI*0,J1jtttiAkplSli?ation To Construct, Repair,-Renovate Or Demolish a
IUU 1t+�lt� One- or Two-Family Dwelling
I This Section For Official Use Only
(w11 Building Permit Number: Date A ied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Pro rty Ad ess: 1.2 Assessors Map &Parcel Numbers
OR
l.la Is this an accepted street?yes---� no Map Number Parcel Number —
IJ 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(fi)
1.5 Building Setbacks(it)
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'
Ott r of Rec i : V1/�� . �' ��
Wo �zn . /�� ��
ame(Print) City Ntate,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s dition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: —
Brief Description of Proposed Work'`:
N
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ G top 1. Building Permit Fee: $ Indicate how fee is determined:
$
❑Standard City/Town Application Fee
2.Electrical
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ L, PAD 0 Paid in Full 0 Outstanding Balance Due:
_ 4
SECTIONS: CONSTRUCTION SERVICES
Sa CnsIrpgdo pervisor 'tense(CSL) /)S - 0 75* 7 1„r
/ //// posh"; License Number Expiration Date
Name of CSL Holder
Lin ` t -List CSL Type(see below)
No. 'treet J L Type Description
/5J U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
CityilomQ,S we,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
S SF Solid Fuel Burning Appliances
( I Insulation
ele hone I Email address D Demolition
5.2 Registered. ome Ie rove entt Contractor(HIC) r;/ _ IIaa
� , 7.ro g ` HIC Registration Number Expir on ate
H C' p Nante or HIC Re strant N a y��J�11�
N . Str e - • I•�
S� —y}I��CI jyn/� Email address
C / own,State,ZIP /U Tele h7olnee �7oICl
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 wilt 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(Elecn3nic 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 my knowledge and understanding.
i qr�►� Gn�,a�r
Print wner's or Authorized'Agen (Electronic Signature) Date
NOTES:
1. An Owner who obtains a building per-nit 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
wvm.tnaLss.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dys
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. 8.) 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"maybe substituted for"Total Project Cost"