B-19-421 - 0002A BUFFUM STREET - Building Permit ilir'
The Commonwealth of Massachusetts
Board of Building Regulations and Standards P ZCIITIAM
Y OF
WMassachusetts State Building Code,780 CMR
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
^ ' One-or Two-Family Dwelling
V This Section For Official Use Only
Building Permit Number: Date Applied:
B01ding Official(Print Name) Sign a Date
1' SECTION 1:SITE INFORMATION
1.1 Pro erty ddr 1.2 Assessors Map&Parcel Numbers
---
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: a ,1 Property Dimensions:
6<10 0
Zonmg District Proposed Use t Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard S e Yards Rear Yard
Required Provided RequiredJ Provided Required Provided
1.6 W ter Supply:(M.G.L c.40,§54) 1.7 Flood Zone Informatio 1.8 Sewag Disposal System:
Pub4 Private❑ Zone: _ Outside Flood ne? Municipal On site disposal system ❑
`w1 Check if yesIV
SECTION 2: PROPERTY OWNERStt]P'
2.1 Owner' f Record: 11 � 1 ems. a
Name(P ' t City,State,ZIP /emu
Tv` d
No.and Street Telephone mail Address Al
SECTION 3:DESCRI TION OF PROPOSED WORK2(c ck all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ 1 Repairs(sY4 I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Numb r of nits I Other 0 Specify:
Brief Des ' tion ofPr posed Work 2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ p 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ 'C ❑Total Project Costa(Item 6)x multiplier 'x
3.Plumbing $ ��- U U 2. Other Fees: $ `��k /
4.Mechanical (HVAC) $ �.�—� List: 6'V
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �� 0 Paid in Full 0 Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
cense Numb Jr Expiration Date
Name of CSL Holder
T� 1 M List CSL Type(see below)AA
No.�ndStreet a C/1 v"`(� Type Description
/+��(� U Unrestricted(Buildings u to 35,000 cu.ft.
l� 1 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
r 11 hl _ SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 RegisterSd Home Improvement Contractor(HIC)
r 1 1 ) / HIC Registration Number Expiration Date
HIC Corgwy Name o' r HIC Registrant Name �--
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit in st be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Iss ance 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
r- f
I,as Owner of the subject property,hereby authorize
to act on my beh lf,in all matters relative to r authorized by this building permit application.
a�
Print Owner's Name(Electronic Signature) Date
SECTION 7b:O ERi 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' his apph on is and accurate to the best of my knowledge and understanding.
Print O s or Authoriz gent's Name(Electronic Signature) Date
NOTES:
I. 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 atwww.mass.gov/_d2s.
2. When substantial work is pl nn d,provi the information below:
Total floor area(sq.ft.) Stye (including garage,finished basement/attics,d cks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms a Number of half/baths
Type of heating system 07 L, Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"