5 BUFFUM ST - BPA-12-151 ll� I Fhe Commonwealth of Massachusetts
Jh 6a CITY OF
Board of Building Regulations and Standards SALF_n-1
Massachusetts State Building Code, 780 CMR Re,ised.tfar 2011
L.
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fumilt Dwelling
This Section For Offcial Us nl
Building Permit Number: Date Ap ied:
y Building Oliicial(Print Nmne) ��aw . ,gna ure D to
SECTION 1:SITE INFORMATION
1.1 Proper Ad ess:fFGl irl A, 1.2 Assessors Map At Parcel Numbers
'� �U
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Laving District Proposed Use Lot Area(sq tt) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood"Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 caner'of ord:
�,cn �Al 0 2,ywm I Ati�M /f A �197a
N:mie(Print) ��tt C'it Slate,ZIP
Qbb r 6 M �( 7 tY-� 4,;.
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
Doves �'i./LfV - E I
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and \laterials)
I. Building $ I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
' Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
J. xiechanical 0WAC) S List:_ —_-_
s, :\Icchanieal (Fire $ Total All Fees: S
Su>>ressionl
U Check No. Check Amount: Cash ,\mount_----
6. Total Project Cost: 5�`D/ r ! Q ElPaid in Full ❑Outstanding Balance Due: _
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
LL_�_GLId -4 I icense Number Ex naioi Date
Name of CSI- I folder
List C SL 1)pe(see below)
No, and S(reet -- Type Description
� I c/ , CI Unrestricted(13uildin IS ti to 35,000 cu. It.)
Cit) '- t Stale,ZIP RI Restricted M2 Famil Dwellin
M MaSon
RC Roolin C'ovcrin
WS Window and Sid i-
SI' Solid Fuel Burning Appliances
7 777 1 fnSulation
'fete hone Email:Wdrcss D Demolition
RRegi5.2 tered Ilome Improvemen Contractor(HIC)
B I ��A� 6o.,r, Z Z ?
III C lip, ly N it 111C to nstra lie IfIC 1 egist�tber ixput ion Date
Stre and et
10 6 Email addtcss
Cit /Town,State,ZI Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.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 Issua ce of the building permit.
Signed Affidavit Attached? Yes .......... V 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 authorize A �-/x- L/,V 1,'If-
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owners Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information
contained inpthis
�application is trru/e and/accurate to the best of my knowledge and understanding.
I run Owner s or Authorized. gents Name(h.lectrunic Signature)
NOTES:
FAnner who obtains a building permit to do higher own work,or an owner who hires an wvegistered contractor
istered in the Home Improvement Contractor(HIC) Programf,will nor have access to the arbitration or guaranty fLnd under�\LG.L.c. I q'_A.Other important information on the HIC Program can be fiwnd atm-g;Ov Ica Information on the Construction Supervisor License can be found at pINw.nubstantial work is planned, provide the information below:
rea(sq. If __(including garage, finished basementattics,decks or porch)
area(sq. it.) _ __ Habitable room count
Number of fireplaces----- Number of bedrooms - ------- --
----
NtnMber of bathrooms N ----------------
_--_----- ------._ umbentfhalf`baths
l)pe of heating system ----- --------
-- Number of decks, porches_
l)pe of Cooling s)stem -- ----------- -----
— -- — — Enclosed ------ -- Open
3. "Total Project Square Footage-ma) be Substituted tiff"Total Project Cost" _ ---_--- --