B-17-1202 - 0056 BUFFUM STREET - Building Permit gn'rp - � s
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY W Massachusetts State Building Code,780 CMR SALEM
n Revised Mar 2011
bJ Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
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This Section For,Official Use Only
Building Permit Number: Date pied:
Building Official(Print Name) Signature Date
SECTION4:SITE INFORMATION"
1.1 Property AQdA--s • FW5T
1.2 Assessors Map&Parcel Numbers
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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 :"PROPERTY.OWNERSHIP
2.1 O n 'of Reco d•
Name tint) I � City State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check a hat apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑! Number of Units er ❑ pecify:
Brief Description of Proposed Work:
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SECTION 4:ESTIMATED CONSTRUCTION COSTS'
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ l ,Building Permit Fee: $.2W Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ '2. Other Fees: $
4.Mechanical (HVAC) $ :List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount:' Cash Amount
6.Total Project Cost: $ ❑paid in Full ❑Outstanding Balance Due.
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SECTION.5: CONSTRUCTION VI
5.1 Construction Supervisor License(CSL)
License Number Expirat' n Dat /
Name of CSL Holder
List CSL Type(see below)
No.and Str Type Description.
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
Cityfrown, tat M• Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
!y I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Com y ' ant Nam HIC Registration Exp do D to
No.and treet Email address
City/Town,State,ZIP elephone
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 Issu a 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 _
I,as Owner of the subject property,hereby authorize � _fY)�
to act on my behalf,in all matters relative to work authorized by this building pen t'a-pplication.
Print Owner's Name(Electronic Signafiire)- 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 rate,to the best of my knowledge and understanding.
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Print Owner's or Au orized Agent's N, e( ectro 'c Signature) a e
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.gov/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"may be substituted for"Total Project Cost"
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