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3 1-2R BUFFUM ST - BPA-114-333
0 © z The Commonwealth of Nrassachusetts Board of Building Regulations and Standards Cl'rY OF SALE I' Massachusetts State Building Code,730 CMR Revised Mar1201/ Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Se¢tl0i[FbCOfIlClal UseOnl Building Permit Number;.'. t)af PpitedS;. Budding Official(Pont Name) na�a4disposalsystermn e Date SECTION is SITE'INFORNIATION. L1 Prro,pperrty Addresr. 1.2 Assessors blip&Parce /Z►Ct- I.to Is this an accepted street?yes .ono htap Number ber 1.3 Zoning Information: L4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 1.5 Building Setbacks(It) Front Yard Side Yards Yard Required Provided Required Provided RequProvided 1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewal System: Public❑ Private❑' Zone: _ Outside Flood Zone? b[unici el is Deal s stem ❑Check if es❑ PP Y „ SECTIONZ:; PRChe if 'OWNERSHTPL 2 1 Owners of Record: T:Q.A4K_1i CeU Name(Print) City,State,ZIP 2�&Q ST— Q-)-(o77- +`ftY No,and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORIO'6heck all that apply) New Construction❑ Existing Building❑ Owner-Occupied Q R'epairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Q Specify: Brief Description of Proposed Work': V 5 cvxc SECTION 4: ESTINLATED CONSTRUCTION COSTS- ItemrEedsts: Official Use Only-. . rials y" I. Building1. Building Permit Fee:S Indicate how fee is determined: 2. Electrical ❑Standaid,City/fuwn,Application Fee ` ❑'rotal Project Cost'(Item 6)x multiplier x 1. Plumbing ?- OtherFee4: S t. ,M.-chanic.d (IIList:i. ,,'Mechanical (Fiessulbtel All Fees:SCheck No. Check Antuunt: C;uh Anrouut-.I'ntall'rnicet -- fLl 1'.1id in 1_ull 0 Untmandim; Ihialice Uua: c P SECTION 5: CONs'rRUCTION SFRVICES 5.1 ConstntctionSupervisurLicense(CSL) o�y:rS3 License Number Expiration Date , ame of CSL I loftier List CSL Type(set below) U �s rpnldt- ,7 Description No, and Street Unrestricted Muildin s uo to 35.000 cu. lt. It Restricted 1&2 Faintly Dwelliti City!town,Stute,ZIP 1�vI %clasanr RC Roofing Covering WS Window and Sidin SF Solid Fuel Burning Appliances 4S 7J ( Insulation 1'ele hung Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 4P27114 0r HIC Registration umber Expiration Date IC Company N;una ur ff IC Rcgistmnt Name `ice Fonrolr Email address No.find Street F?Z F•2t 1 �� — Ci /Town,State 'LIP Tele hone SECTION 6: WORKERS' COINIPENSATION INSURANCE AFFIDAVIT(NI.G.L.c. 152.1 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 .......Ag No .......❑ SECTION 7a: OWNER AUTHORIZATION TO DE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PER'NIT 1, as Owner of the subject property,hereby authorize 12b /Ayil, C E2 O 3 S to act on my behalf, in all matters relative to work authorized by this building permit application. &^,4 w� �'• • ✓/A —Date Print Uwncr's Name(Electronic Signature)t SF.CT(ON 7b: OWNEW OR AUTIIORIZEDAGENT 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, Irint L)lvller's or Authurized A;cnt's Name(Electronic algunauc/ Date NOTES: Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Houtc Improvement Contractor(HIC) Program),will Lint have access to the arbitration program or guaranty fund under M.U.L.c. 142A. Other important information on the HIC Program can be found at w ww m;t9i.,�uv%oca Information on the Construction Supervisor License can be found at www.ncu,."wv.'diL" ? When substantial work is pl:tnticd,provide the information below: r. When oor area anti R.) _(including garage, tinisimd hascment/attics,decks or punch) Croii living area(it. it — llumberlo room comet _ iNumber Uttirepi.lcci-_—_.___—_._ Nlllllher of hetlt-baths Vumbcratbatilr,,,,lll; --_--_-- NumbenofhalGhaths .------__---- f�pcolheeting ;y;lelll \nndwrufdccki"porcllus _ —_--- __. _-- ;y.lCl1l ('.IICIu.icd. � I,,LIi ud Foot.,.,a"way he cil I'rnjed