25 BUENA VISTA AVE - BPA-13-238 t
The Commonwealth of Massachusetts
`\ Board of Building Regulations and Standards CITY OF
p ► ®\0 Massachusetts State Building Code, 780 CMR SdMar Revised Mar 7011
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/Applied:
Ito-,
Building Official(Print Name) - Signature V Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel umbers
a5 B�ienc VISh0. Avf . UUU00q' (:>w Hl 5
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 Owner'of Record:
IOfI �lunf� S� Ie(M. IOW OI Qn�
Name(Prim) City,State,ZIP
25 13ueoa VIS�G Ayr— grng-LlO-iaU7r
No.and Street CO le rn Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) E91 Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
InS+GII Ofye t)nrj WlnLiOLO tn+o >°,c1 �OPrrl r-)5
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1. Building $ 5 L4 I q 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $
❑Standard City/Town Application Fee
-
❑Total Project Costs,(Item 6)-x multiplier x
3. Plumbing $ 2. Other Fees: $ -
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $ --
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due: .
4 40,Oa
t
LI. �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 0 Z Cj Oai O
II- (q-13
—rj-�(7 mG S P. FC:) X or l License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
2C� CedQv S�
No.and Street Type Description
W o h t-\r o � ^ ^ 0
1 To U Unrestricted(Buildings u to 35,000 cu.ft.)
1"�` R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
_1 fr I.43� 8�U0 F�XU'nC+ fle uprtl • I Insulation
Telephone Email address Conn D Demolition
5.2 Registered Home Improvement Contractor(HIC)
New rU I(1 (o59 at 13
HIC Registration Number Expiration Date-
HIC Company Name or HIC Registrant Name
2(� Ccclar St
NO and
Street
U r n "A O 1 Y-01 &I 01 Jo'- g300 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 CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize TPA 00Y)O r P - F o K on
to act on my behalf,in all matters relative to work authorized by this building permit application.
-DOn F (gnr \
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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 best of my knowledge and understanding.
T1�pmA� P. FOxOa1
Print Owner's or Authorized Agent's 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.eov/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 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"