4 LOWELL ST - BUILDING INSPECTION L
i The Commonwealth of Massachusetts CITYOF
Board of Building Regulations and Standards SAL M
Massacusettstate h S Building Code, 730 CNIR Sd Mar�Y7 Revised tLlnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official UseOply
Building Permit Number. Date plied'
S' P3
Building Official(Print Name) 'Signature Date
SECTION [:SITE INFORMATION.
l.I Property Address: 1.2 Assessors Map Br 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.0.E c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public M' Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes13
SECTION 2:; PROPERTY OWNERSHIPL
2.1_ ,Pwnert 7J of RccyF I (%
r
Name(Pr(Print) y w City,State,ZIP
y,, yy—��/v/ {q
No. and Street - Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW'(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':
ivs r-,vv1 T�1Cr..5
G,tcf lP5 s J 0 I h M ^ L2,
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Estimated Costs:
Item Labor and Nla Official Use Only.
rrials
1. Building ; I. Building Permit Fee:S` Indicate how fee is determined:
Electrical $ ❑Standard.Cityfrown Application Fee
❑'total Project Costr(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
1. Mechanical (IIV.\C) S List: .
i. Mechanical (Piro 5
1n essum) rota! All Fees $
Check No. Check Alliotmt: _ Cash \nwiutr _
, 1'14.11 Project Cost: ) ylk p Pail m Pull Cl Outstandut" 11 dance
�aMe Or✓,��li-
i
SECTION 5: CONs'r►tucrION SERVICES
5.1 Construction Supervisor License(CSL) ^ r
er.� License Number Expiration Uuto
Nammee of.CSL I folder )) List CSL Type(see below)
Type - Description
No. and Street
a ln r fed 3uildin s u cu. tt.
X"G R Restictel 132 Family Dwelling
Citylfown,State, Z �t Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
2s� "y>a -7s'y [ Insulation
Telephone Email address D Demolition
5.2 egistered Home Improvement Contractor(FIIC) U�Y1 L Sf14Z /'
;44. j 6 co Caa � -IIIC Registration Number Expiration Date
I(LC Comp n
Name or Ii1C Registrant Nme
J<J -r-w ✓ts�- ( nwZ
3—Z,y"!7
Email address
City/Town, ST, ZIP 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 .......... S� No...........Cl
SECTION 7a: OWNER AUTHORIZATION TO DE 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 7h: OWNEW 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.
Prl❑t L)lvntf'i Jf AUd1Ufl LCd:� nt's Nnntz(Electronic Signature) Due
NOTES:
I. :\n 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. I42A. Other important information on the FIIC Program can be found at
www m;u>.euv;oca Information on the Construction Supervisor License can be found at www.ma,s-ivy L
2. W'hen substantial work is planned,provide the information below:
rotaI floor area(sy. It.)
(including garage, finished basement/attics,decks or porch)
tiros; living area (,ill. tl.) _-- Habitable room count _
Number of ti rplaccs_-----,---— Number of bedrooms --------
Nuntl;eruCbathroums Number ofhaltbaths -- -
--
fcpeofheatingVitant -- ---_._—.- Number ofdeck.,•,'porches
)peofcooliitg ;Y'lQlu ------ --"--" - ----- Enclosed.-- - - (,Pell -------------
-------------
� 1. `I',tl.el l'r��j�`it 1yu:u'a I�rnN.tge'' in.ry he ;ub;tiurt.J ra "f�d.il l'r��j�dl',rt"
CITY OF 5.1L.E1pI, >tiL15S,1 CHUSETTS
s BUILDING DEP.1ATh(ENT
) ' )' 120 WASHINGTON STREET, 3'FLOOR
TEL. (918) 745-9595
F.kx(979) 140-98.16
t<i.%(BEnEY DRlSCOLL T HO'%W ST.PMUS
MAYOR
DIRECtGR OF PUBLIC PROPEA'[Y/0l:[LDNG COJINIISS(ONEA
Workers' Compensation insurance Affidavit: Builders/Contractorv/Electricians/Ptumbers
Altlicant informatfnn // Please Print Legibly
Vault iousincss. Vnirati tru Individual):
Addres
City/State/ZIP: / � �"' Phone
,\re you an employer?Check The appropriate boss Type of pro)eet(required):
I.0'ram a umploycr with C 4. 0 I am a general conli actor and 1 6. []Now eonsuuction
employees(full and/or part-time).• have hired the sub-uontractarx
2.0 I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These subcontractors have V. 0 Demolition
working for me In any capacity. workers'camp.insurance. 9, 0 Building addition
(No workers'comp.insurance S. 0 We are a corporation and is
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,01(4),and we have no 12.0 Roof r pair$
insumnca required.] t cirplayeps.(No workers'
comp.insurance required.) 13.0 Other
;Any appan lict din dnv:ke box 1I mint 36u nil out Ihs uctico below showing their"km*mmpenudua pulley inib matlon
I bvnauwm"who pdimit this atildavil indicming liter aro doing oil wok and slits hlro outeidecemroctaa mint suhmlt a now artldavit indlmdng puck
:C nntmuturs that chacl this boa must anaehad an addidunal shad showing the name of the puhavniractors and Ihalr workers,comp.policy InWmuanon,
l aim an employer that Is providing ivorke»'compeuradon hrt�ce for my employees Below is tho polity and Jub silo
In\Ulanee Company Name:
1'ulicy 4 or Srlf--its.pL�iicc. : J ��`� 3 —�bl `1 f`L 3��r� „ Expiration Dote:`Z�Z eG��y •-
Job Site Address: % City/Statr/2ip: eJ l.✓G``, �"L'r
Altach a copy of the workers'componsatlon policy declaration page(showing the policy numbor and expiration data).
Failuro to sucurts coverage as required under Section 23A of MGL c. 152 can lead to the imposition oferiminal penalties of a
tine up to S1,500.00 untVor one-year imprisonmcnq as well as civil penalties in the farm ofa STOP WORK ORDER and it tine
of up to S250.00 a day against ilia violator. Ile advised that a copy of this matemunt may be forwordud to the Oftica of
Investigaiiuts of the DIA fur insunnca coverago wrilicatiun.
l du lureby cart! nt Jet that point cord penult! afReffa of the bryarnratime provided ubbuyee is true cord cdrreet
iicnantre' I)a to' O G
I
Oljf W ape mdy. Do nor mritr in th/s urra,to be cuntpleled by city or tdwn nJJirlait
i
I Ciry or'fown: ._ _ Pvrm(r/1.fecnsa:Y
I.itilois Aulhurily(circlo acne):
I. 0purd of Ileallh Z. Building Deportment .1.CilylfusruClerk .1. [aeetrlealLu"Ituri. I'lum0,14lnspecrar
Contact Person: