B-17-778 - 0061 BUFFUM STREET - Building Permit - zg -z t
c� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY ,
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For"Official Use Only
Building;Permit Number: Date lied: �1
Buildmg Official(Print Name) Signature ate
. :
SECTION`1:.SITE INFORMATION
t 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers co x�
�:
l.la Is this an accepted street.9 yes no pµ
Ma Number Parcel Number r e -
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 caner'of Record: � A� � 510
c� �. c_. M
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR 0:(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work2: _ S
SECTION 4 ESTIMATEDCONSTRUCTION COSTS`
Estimated Costs
Item Official Use Only
(Labor and Materials
1.Building $ L Building Permit,Fee: $ : Indicate how fee is.determmed:-
2.Electrical $ ❑Standard City/Town Application Fee
❑Totai Project Costa;(Item 6)x multiplier . x
3.Plumbing $ 2. Other Fees. $
4.Mechanical (HVAC) $ List:
5.Mechanical ire
Su ression $ Total_All Fees:$
6 Total r Check'No. Check Amount: Cash Amount
ota Project ect Cost: $
J U
q�� 1-01`aidm-Full �.: ❑Outstanding Balance Due:.
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
&J\oe,\ t CS^Oc�C)Z� License Number Expiration Date
Name of CSL Holder A
List CSL Type(see below) lJ
No.and Street I Type Description
lam_ V hJ cf)moo U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofin Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Nol�&4, d"4t1 - I Insulation
Telephone Email address D Demolition
5.2 Registered Home improvement Contractor(HIC) S _
HIC Registration Number Expiration Date
C Co pan Name r IC Registrant Name � 5 CIS tJ`V_�o
o.and Street t
TAfi (tit`aWKs —�'`� o CpC) 1� Lf Zo`"S� Email address
Ci /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 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 permit application.
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
contained in this application is true and accurate to the hot of my knowledge and understanding.
t Owner's?9kuthorized Agent's Name(Electr nic Signa e) Date
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"may be substituted for"Total Project Cost"
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