2 BUFFUM STREET EXT - BPA-13-847 q^
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY/ USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Sect on For Official Use Only
Building Permit Number: : Date ]led
Bui ding Official(Print Name) igta � Date
SECTION 1.SITE INFO A
1.1 Propbrty Ad ess: S E J� 1.2 Assessors Map Parcel Numbers
d— U/Y� 1`
l.la 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 OWNER Sflip.
2.1 Ownert oRecord: �-o. 6
u nd. �o f en
Name(Print) City,State,ZIP
�)- 8 ,,. C�� .r1 Sfi EXf 97f-)y3=19lu
No.and Street Telephone Email Address
SECTION:3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': L3e,- sFr n 6o r 5
& /ig rC�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item OfTcial Use Only
(Labor and Materials
1. Building $ 1. Building Permit Fee::$ Indicate how fee is determined:
2.Electrical $ O Standard CII
Application Fee
Total Project Cost (Item 6)x multiplier _ x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: t �
5.Mechanical (Fire $ Total All Fees: $
Suppression) -
Q D 8 Check No. _ Check Amount: Cash Amount:
6.Total Project Cost: $ G /Q ❑paid in Full ❑Outstanding Balance Due:
SECTION 5:CONSTRUCTION SERVICES'
5.1 Construction Supervisor License(CSL) C T)
License Number Expiration Date
Name of CSL Holder l �hD}�
3I' i1 StMt List CSL Type(see below)
No. and Street C1Il Wil Type; Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
lJ / RC
Covering
WS Window and Siding
`/ c SF Solid Fuel Burning Appliances
7 7 —p j y - I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) �y Zo 9 3 �), /d
Atlantic Weadierizatim,1-1-C HIC Registration Number Expiration Date
HIC Company Name or HIC RegMak x10�I�,�>sm Avenue
•"r/70, 1,17 61 0—
No.and Street Sa Cnl M1 01970 Email address
Cit 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 o 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 c" t'_
to act on my behalf,in all matters relative to work authorized by this building permit application.
tat, PAt`e-n � L—. f�.w 7I3
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.
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. ovg /oca Information on the Construction Supervisor License can be found at www.mass.gov/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"
1
WAP Work Order: Job Number: 110527
Contractor Instructions:
Before Starting the.Job: During the Job:
1.Please notify us 24 hours before starting or scheduling a job. 1.Incorporate lead safe practices as applicable.
2. Obtain required building permit. - 2.Total for Heath&Safety and Repairs cannot exceed$2500.00.
3.Davis Bacon time sheets required for ARRA work on US
Department of Labor Certified Payroll Report Form WH-347.
Additional Contractor Instructions: -
Certificate of Insulation posted? Yes No Fircle One) Attic Inspection form attached? Yes N/A (Circle One)
Where PosQ:'ner J,,,,,t
ContractoY:`t�antlCDate: WAP Auditor: Date:
Energy Director: / Date: Fiscal Officer: Date:
FOR AGENCY USE ONLY
Pre Post Language Other than English needed? Yes No (Circle One)
Dryer CO 0.000 If Yes;indicate language:
Stove CO 0.000 Occupany change in last 18.months? Yes No (Circle One)
H2O Tank CO 0.000 Comments:
Heating System CO 0.000 Number of windows
Ambient CO 0.000 - Number of rooms
Blower Door 0.00
Date: 5/3/2013 Page 3