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4 BUENA VISTA AVE - BPA-2009-297 The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of �r Massachusetts State Building Code, 780 CMR, 7ih edition Wilbraham Building Dept Building Permit Application To Construct, Re air, Renovate Or Demolish a 413-596-2800 One-or Tivo-Fzoni!x1Dvvk11ing Ext 118 This Section F r Qffici I Use Only Building Permit Number• a plied: Signature: _ ��"� io�� 0,53 Building Commissioner/Kspector of Building Date SECTION 1: SITE INFORMATION 1.1 Pr peI Address: 1.2 Assessors Map& Parcel Numbers L/ /5u.e Ka Vr��o Al 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 -__ I•i,o r r t - .; h) --^� Frontage(R) 1.5 Building Setbacks(.ft) Front Yard Side Yards Rea,'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: Mar{;n Norwood q&-e7taV5fa4✓e �112S1 Name(Print) Address for Service: 4 i-7- 83 S�-OW Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ 1 Existing Building ar I Owner-Occupied 0'1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition 10Accessory ;41+{g. ❑ Number of Units Other ❑ Specifv: i B-.'e.F Description of Proposed Work' . _ C P K I o-4 L, 5 r e d e 2 Da;r t'-c. I * a t I 5 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building 23 K 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ U K ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ K 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 3a�( ❑Paid in Full ❑Outstanding Balance Due: 30 c2 is , � / � 7 ��o� © l� h c� SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License%Tympbler Expiration Date Name of CSL older List CSLe below) Address Type Description U Unrestricted-Np to 35,000 Cu. Ft. R Restricted 1&2 Pamilv Dwelling Signature M Masonry Only RC Residential Roofing _ verin Telephone WS Residential Window an Sidm SF Residential Solid Fuel Bum B, mm Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signa orr 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. Si n_a_m_re of Owner Date 1., SECTIO 7b: OWNEyW OR AUTHORIZED AGENT DECLARATION I, O`r ,as Owner or Authorized Agent hereby declare that the statements and information on the fore ing application are true and accurate, to the best of my knowledge and behalf. Print Name /� Io a� Signature of r or AuWrik6d Agent Date Si ned on&the 2ains and penalties of perjury) NOTES: I. 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 I IO.R6 and I I O.RS, respectively. 2. When substantia! work is p!a:ned,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"may be substituted for"Total Project Cost"