B-17-435 - 0039 BUENA VISTA AVENUE - Building Permit The Commonwealth of Massachusetts
Board of Building Regulations and Standards ; , CITY,QF
WMassachusetts State Building Code,780 CMR 1"0 " - W
Revised Mar 2011
Building.Permit Application To Construct,Repair,Renovate Or Demol' h i]t 3
� One-or Two-Family Dwelling Ld�� 2 A
TVs.Section For Offtcnal IJse Only
Buildnng Permtt Nttber. : Date lied:
.� l3uilding Offie�al(Prmt Name) Signature . , Date.
P SECTION:1:SITE INFORMATION
1.1 Prope�Address: 1.2 Assessors Map&Parcel Numbers
3 1 F�/q- V.es / f�e
1.1a Is this an accepted street?yes .ono Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(8)
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: PROPRRTY OWNERS.HV..
2.1 gwner'of Record:
Name(Print) City,State,ZIP
311 Gve&o' yl sum
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED'WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)X I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work-2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
labor and Materials
1.Building $ `j Oco— 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
O Total Project Cose(Item 6)x in, X.
3.Plumbing $ 2. Other Fees: $ .
4.Mechanical (HVAC) $ _ Last:
5.Mechanical (Fire $Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ Dv0' ❑Paid in Full ❑Outstanding Balance Due
i
SECTION 5: CONSTRUCTI0N SERVICES
5.1 Construction Supervisor License(CSL)
gg (Xi 9-53 �
license Number Expiration Date
Name of C81,Volder
List CSL Type(see below)
&mn`= tU Des hon
No.and Street ;
U Unrestricted(Buildings up to 35,000 cu.ft.
in l d LO 7 Restricted 1&2 Family Dwelling
City/Town,Stite,-ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
' 1 I Insulation
Telephone Email address D Demolition
5. a stere�d�ome Improvement Contractor(HIC)
�4I ��S �� 73 �L
/ C Registration Number Expiration Date
HIC Compan ame or HIC Registrant Name
�Street- W` e Email address
010�-City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION][14SURANCE.AFT+TDAVIT.(M.G;L.e.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..........RQ No...........❑
SECTION U OWNER AUTHORIZAT ON TO BE COMPLETO D WREN
OWNER'S,AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize I €x ,�
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 application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic 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
wwnv.mass. o� v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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"maybe substituted for"Total Project Cost"