B-17-1034 - 0056 BUFFUM STREET - Building Permit 24g1(D
G k'a L
d SIj'" .t. 1.
The Commonwealth of Massachusetts `1ae'�,( ',Z s ; -
�" Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section Bo .Official`.Use Only
Building,Permit Number:. Date,Ap re .
:Building Official(Pant Name) " Signature: Date
SECTION:,SITE INFORMATION,,
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
l.l a Is this an accepted street?yes ho Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq$) 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 2r,PROPERTY.OWNERSHIP'
2.1 Ow r' Reco d:
104- w ..
Name( rint) —_ City,,`�/�5 State,&P
ii{'h� C
No.and Street r —Telephone Email Address
SECTION 3:DESCRIPTION OF,PROPOSED WORKz(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ETJ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units 9thg ❑ S eci
Brief Description of Proposed WorkZ
s
SECTION.4 ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials a;
1.Building $ 1. Building""Permit Fee:$ Indicate how fee is determined:
2.Electrical $ LM ❑Standard City/Town Application Fee
❑Total Project Costa(,Item 6)z multiplier x
3.Plumbing $ 2 ,Other Fees: $
4.Mechanical (HVAC) $ List.
5.Mechanical (Fire $
Total All Fees:$
Suppression) ..
Check No Check Amount Cash Amount
6.Total Project Cost: $ ❑Paid`m Full ❑Outstanding Balance Due-
* SECTION 5 CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
9w—Cl�t '1 License umber Expirati D e
Name of CSL older
List CSL Type(see below)
No,an treet Type Description
t C f ,� U Unrestricted(Buildings s u el ing cu.ft.
F`47�_`V`—'� ` 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
Tel oh'nc_ Email address D Demolition
5.2 Registered Home ImprovgMot Contractor(HIC)
1I�7 �
HIC RegisTiation Ni1mber Exp' do a e
HI o a e stran ame
No.an t V L } Email address
City/Town,State,ZIF Telephone
SECTION 6:`WORKERS'COMPENSATION'INSURANCE AFFIDAVIT(M.G.L.c:152.§ 25C(6))
Workers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu of the building permit.
Signed Affidavit Attached? Yes ..........6 No...........❑
._SECTION 7a:OWNER AUTHORIZATION-TO BE-COMPLETED WHEN Y
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 ermit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b OWNER10 AUTHORIZED AGENT DECLARATION.
By enterin my nam below,I hereby attest under the pains and penalties of perjury that all of the information
containe in ap icati is true and accurate to the best of my knowledge and understanding.
er's or thorized Agents 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
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"