14 RUSSELL - BUILDING INSPECTION 7� � 4 $LA (s
(5 GZ-V tT--, 7bT-` SM o,
The Commonwealth of Massachusetts CITY OF
* Building Regulations and Standards
a ldtte Building Code, 780 CMR SALEM
tiSPECT) Revised Mar2011
Buil(Titig Permit Application To Construct, Repair,Renovate Or Demolish a
Ane--�o35wo-Famil),Dwelling
.,.±t€+- �This Section For Official Use Only
Building Permit Number: 111 , Date App
N A~ b
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
f 1.l PropePAd'd 1.2 Assessors Map&Parcel Numbers
1.1 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 ft) Frontage(ft)
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 Own u of Recor!.
/I r � l dDl
me(Print) City,State, IP
5b0 W4 omments aAK
No.and Street .Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
-
Brief Description of Proposed Work': IMAQ
f
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ d� 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 $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
.Check No. Check Amount:- Cash Amount:
6. Total Project Cost: $ /(OP ODD 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervts icense(CSL) �� ' ,7
�f //�yr•t h� oal ense Number Expiration Date
Name of CSL Holder r'
T P / I YQI List CSL Type(see below)
Type Description
y / /� • U Unrestricted(Buildings u cu. ft.)
Ciry/Towq State,ZIP /� R Restricted 1&2 Famit Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
•3^1.506 bn1�v SF Solid Fuel Burning Appliances
`� ff)q I Insulation
Telephone Email address D Demolition -
5:�2 Registered
//I401ne Ippro�vifneent Contractor(HIC) '1 �2 `1 G/_
VV�r✓ t Vn ]/I U U I!)Y] HIC Registration
e•7Jon NNum{lber Expiration Date
H i pury ly,�n�ao� C_�2 ��S q Gems _ III RRReeegggiisssntrtraaatttiii
N � ISnet �1�cD►')S��IA�}�N�•
i� t./^ an•51AD Email address
Ci / wn, State,A P 0/Telephone
-�/�
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.........ce�—
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 penhit 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 thl application is true and accurate to the best of my knowledge and understanding.
IG0 nvGs ,
Print O er's or Authorized Age ['s e(E! onic Signature) Date
NOTES:
1. 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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. 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"