B-19-522 - 0005 BUFFUM STREET - Building Permit .,C%
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code,780 CMR SALE
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only e!
I� Building Permit Number: Date Applied:
IV :e .
Building Official(Print Name) Signature Date •..-
1 SECTION 1:SITE INFORMATION
�-- 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers '
1.1 a Is this an accepted street?yes no Map Number Parcel Number
g
1.3 Zoning Information: 1.4 Property Dimensions:
►�1.
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'
2.1 Owner'of Record:
Pc-,P-& S,�L (A O l Ci 7 C)
Name(Print) City,State,ZIP
5 r1-\ q)g 83s- 1171
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building V Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
ion 1 % �O
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 54 0o
1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical
❑Standard City/Town Application Fee
$ ❑Total Project Costs(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: $ 5-10d 1 ❑Paid in Full ❑Outstanding Balance Due:
'S
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
O n �JC�I Y� License Number Expiration Date
• Name of CSL-Holder j
10(-a Q1 ei -t2ca t List CSL Type(see below) (�
t
Address Tvpe Descri lion.
U Unrestricted(up to 35,000 Cu.Ft.)
Sig ature R Restricted 1&2 Family Dwelling
M I Masonry Only
Telephone
le y y -l lI RC Residential Roofing Covering
Telephonn e WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
S-o vn n teal ( L]
HIC Company Name or HIC Registrant Name Registration Number
e n
Address
191 Expiration Date
Sifnature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.Gt.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 .......... 07 No p
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize _ __ to act.on my behalf,in al matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, n t -� ,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 and
behalf.
�r n r-,
Print Name
Signature of OEvner or Authorized Agent Date
(Signed under the pains and peaalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I O.R6 and 110.R5,respectively.
2. When substantial work is planned, provide the information below:
Total floors 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"