B-17-1129 - 0040 BUFFUM STREET - Building Permit r
The Commonwealth of Massachusetts r FOR
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR MUNICIPALITY
(57 Building Permit Application To Construct,Repair,Renovate Or 1 ?0 Xevi ed ar 2011
One-or Two-Family Dwelling
This Sectiori'For Official Use.Only
'�'' Buildmg Permit Number Date Afplied. '
1
$wilding Offhchal(Pent Name) 'Signature ate
SECTION 1;SITE INFORMATION
lip Addles J 1.2 Assessors Map&Parcel Numbers
L l 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.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 ner'of Recor : � In
q �� 0 s lJ 1
k(
Name(Prin r City,State,ZIP
r 1 M_; _. 0p
No.and Stet Telephone Emai ddress"
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: KiaM t0 n0sLt ri L, K A r-C_1tns3
t..3 I t..3 «J
1]_t,1�_T i?�"'(`n�'�U d-� -i t`S C'�t� •�'7 P�f�. t�i y �f�-1,��.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:'Item Labor and Materials Official Use Only
r A.Building $ "1. Building Permit Fee:$ Indicate how fee is determined:
2..Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
-$u ression $ Total All Fees:$
( \ Check No. Check Amount: Cash Amount:
\. 6.Total Project Cost: $ � ❑paid in Full ❑Outstanding Balance Due: .
h 2q M tit ueD Tk�) K, Q.
SECTION 5 CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or 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 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 .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR C.ONTRACTORAPPLIES FOR BUILDING PERMIT
1,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.
7
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
containe in this applic ion ij a and accurate to the best knowledge and understanding.
a losYV Pri Owner's or Ayffiorized Agent's N me(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
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass. og v/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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"