33 BUENA VISTA AVE - BPA-2008-1076 The Commonwealth of Massachusetts
Board of Building Regulations and Standards I (Hz
Massachusetts State Building Code. 780 CNIR. 7"' edition
1
Building Permit Application To Construct. Repair, Renovate Or Denntlish a KrrisrJ./,h
�numu,
O Once- ur Tu o-Family Du ellut,t,
This Section For Official Use Only
Building Permit N nbe : Date Applied: Li • 27•
$ •
p $Ill natar G6e: , - ---
Building Cunumssuutcd Inspcaor of Buildings Date
7
' SECTION I: SITE INFORMATION
LI Pro r" Address* 1.2 Assessors Map & Parcel Numbers
�-1 1 as is this .n accepted sneet'_yes"____. no_ Map Number P,UCel Mantra
I.,i 'Zoning Information: _ --__----- i 1.4 Property Dimensions:
�� Zo--ning District Proposed Use I Lot Area(sy 11) Frontage(it)
Building Setbacks (ft)
Front Yard Side Yards Rear Yard
--
Required Provide) Required Provide) Rcyui red_ Provided
1.6 Water Supply: (M.G.L c. 10. §54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public ❑ Private❑
Zone: — Outside Flood Zone'' -
Check if yes❑ Municipal ❑ On site disposal cys:em ❑
SECTION 2: PROPERTY OWNERSHIP' _ _ i
2.i --I—
of rd:
Na a (Print) Address for Service:
Signature ' Telephone ASECTION 3: ESCRIPTION OF PROPOSED WORK'(check all that apply)
New Q;nstruction ❑ Existing Building [Owner-Occupied Repairs(s) Alterution(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ I Number of Units__J Other ❑
i Brief Description of Proposed Work-: -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
'Labor and Materials)
1. Building $ I. Building Permit Fee: $ -' _ Indicate how fee is determined:
Standard City/Town Application Fee
?. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x _
I
3. Plumbing $ 3. Other Fees: $ !
I
4. Mechanical (HVAC) $ List:
I
5. Mechanical (Fire $ -
Toed All Fees: $
Suppression)
Check No. Check Amount: _ ('a.h .-\moune _
6. rotal Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:_____
SECTION 5: CONSTRUCTION SERVICES
` 5.1 Licensed Construction Supervisor(CSL)
License Number Fxpitanoo Date
Name tit CSL- Ifolder
List CSL Type nee hcloa) _
T c Dcscri itiun
\ddrrss
L Unrestricted(up r to 35.000('u. Pt.t
- R Restricted I&I Family D%kelline
Signauue '1 Iasonrt Only
RC Residential Roolinc C'usrnle
Telephone \\'S Residential \V indm% and Sidhn- -
SF Residential Sold I Burnme \>>h:m.e Inst.tlluunn
D Residential Demolmon
5.2 Registered Ilorne Improvement Contractor 0110
HIC Company None or HIC Registrant Name Registration Number ---
Address
Signature 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. Fat lure 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,
1. _.__ _,,as.Owner of the subject property hereby
oarnv mall matter.;
reiativ.;zo'.work aut'.o.razedby.this.budat grerf,iiapplication . .. _
Si nature of Owner Dute -
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
i NOTES:
L An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL) can be found in 730 C'MR Regulations I IO.R6 Lind I IO.R5, respectively.
When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished base men Uattics, decks or porch)
I Gross living area ISq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of halt/baths
Type of heating system Number(it decks/ porches
Type of cooling system Enclosed Open _ .---
3. "Total Project Square Footage" may be substituted for "Total Project Cost'