11C RUSSELL DR - BUILDING INSPECTION The Coinrtun�realth of Mas,aihusells
t 13uald of Building Regulations and Standads L( Ht
?IINII II' \I II l
M:Issachuscit; State Building Code. 7SO (AIR. 7u' editionOf til Q
Building Iirnul Application To C'unstntrt. Repair. Renosatr Or Drnutlish a -
One- or Tn u-/vunilc Du rllin,� _ors' CV`,
This Section For Official Use Only
Building Permit Nun her: Date Applied:
nuJ A nun;..urned In Pectur ur Buildings Uam
SECTION N 1: SITE INFORMATION
Ll // C ty l-s5fil D P i1 :\sses;urs Dlup Purccl Numbers-- -__
I
M1ia Number Pau:r! .Number
L I:t Is This an accepted street yes__ nu P
Lefurrnalii:n: 1.4 Property Dimensions:
!.3 Zoning
Zomng District Props,sed Use Lot Area(sy fit Fnrutagc (iti
1.5 Building Setbacks (ft)
j Front Yard S de Yards Rear Yard
! Rryuired Provided Rcquned- P:uvided Reyui, Pn;,T&-! -
_ I
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zmie Information: 1.8 Sewage Disposal System: i
Zone: _ Outside Flatd Zone:' Municipal ❑ On site Jis weal syacm ❑
Public ❑ Private❑ Check it yes❑ p I
SECTION 2: PROPERTY OWNERSHIP'
2.1 Oomerl of Record:
N.aw iPrint) Address for Service: i
S'gn:�m KZ
rc N 3: Telephone
SECTIO DESCRIPTION OF PROPOSED W R (check all that apply)
PJew iConstruction ❑ Existing Building ❑ O•s nee-Occupied Rep.urs(s) Alterut(rnla) Additioq ❑
Demolition ❑ Accessory Bldg. ❑ -+—Number of Units_ Other ❑ Spccty:_
Brief Description of Proposed Vv'ork';-419
I
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
item Labor and Materialsf Official Use Only
Vilannical
Building S 1. Building Permit Fee: 5 Indicate how fee is JrtennlnrJ:
❑ Standard City/Town Application Fee
trical $ ❑ Total Project Cost' (Item 6) x multiplier s _
I
bing S 2. Other Fees: .S MVAC) .$ List:hanical (Fire 5 —
fund :\II Fees: $
Suppression)
Check No. Check Amount _ ('.t.h \nn uuv:
j ost S /�ao
b Folai Project C 0 Paid in Full 0 Outstanding Bal:mce Due:---- - ._
SECTION 5: CONSTRUCTION SERVICES _ 7-. .1
5.1 Licensed Construction Su'perrisur (C'SI.)
_7,`C- AIA4 Ae, , /�� I_icrn,i .Vumhrr I`.,plr.w�m Ddir
Nance A ('SI.- Ito dcr�"�--�
A —.90-7 �� Lul CSLf,pC I,er hrluw 1
l � fr c Dr.�rl ,Ilan
I ( nrC,nIC1e L@ J Itl,lo 7i,1NIll\k
R Rrsm,ted _' Fainik D lhne
en -y
Slgn:u re \I \la,onn Onh
q?f s�71—AA,30 RC Re>iJrntlalRun, ('u,cilI,, j
l frlrphune RS Rcmdcuoal NIl:duw and
S1= R:.IJ:uu.tl S,ilJ Furl lSw nuc• Aj,j,lLmr: u.I,J .11im
U Rr,iJcutLJ Dr111Uho"'i
egistsr.ed Home Impr}tvt(_ LA Contractor I IIIC'1
hhiMN'eiN CC���4C..
it l(,,,Comy,,any Name or H ' Regu an am, Regutranun Numhcr
I As Mfg
Address ---
i9Z' -�'nq7cjo ExplraG,m Date
Slgnatute relephune
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pnr\Ide
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
1 , as Owner of the subject property hereby
authorize_ to act on my behalf, in ;d n l utters
-e!ative to wook authorized by this building permit appl iration.
i
Siunature of Owner Dote
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge turd
behalf.
Print Name
Sienature at Owner or Authorized Agent Date
ISi tied under the urns and penalties ofper-jury)
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work. or an owner who hires an unre�a,tered c,mmil.hn
(not registered in the Home Improvement Contractor(HIC) Programl. will not hale access to Ise arhinantm
program or guaranty fund under M.G.L. c. 142A. Other important inti n mation on the FIK' Pn,grun and
Construction Supervisor Licensing (CSL)can he tound in 780 CNIR Regulations 110.R6 and 1 10R5. re,pecoscle.
' When substantial work is planned, provide the information below:
Total floors area ISq. Ft.I (including garage. finished hasentent/aw". decks or porch,
Gross living area (Sq. Ft.) Habitable roost count
Number nt it,eplaces Number of bedrooms ----- _--_---- -
Number of hathrooms - Number of halt/hash,
Tvpr of heating sy,tem _ Number of Jeck,/ pi,rchc,
Type of eooling ,yslc nt _ LnclooeJ ____---_Opcn
z. "Total Project Square Footage" may he ,ub,tituted too "rotal Project Co,("