6 BUFFUM ST - BPA-11-376 ,\ The Commonwealth of Massachusetts
^ Board of Building Regulations and Standards CITY
\hN Massachusetts State Building Code, 780 CMR, 7 s edition OF SALEM
` \ Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a I, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:Signature: told d A
//d
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property As: 1.2 Assessors Map &Parcel Numbers
ddres
1.1a 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
for ,-�)- �t (_o S-t x2aNa
) ) Address for Service: /A
6ature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) .,,..�
New Construction❑ Existing Build-0 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brilf Description of Proposed Wor 2. '
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa(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: $ Iqq AM0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ----u z 'I
\ License Number Expiration Date
ame of CSL-Holder
�--) � C W t 1 \ List CSL Type(see below)
no �V \��
s a Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted M2 Family Dwelling
nature G� /� / M Mason Only
0173� `� "'1��i RC Residential Roofing Covering
'filephon WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5. egistered Home Impm!vcnt;ontractor(HIC) \�dQ�\��,� �
HIC Company Name or HIC Registrant Name Registration Number
ptrauon Date
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. 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
A.
I, ��Oori A�- � = ) 1 \�� as Owner of the subject property hereby
authorize A� (1,(,C6� Ca to act on my behalf,in all matters
relativ rto work authorized b}}�f this building pe 't application.
Ia"Ta7ry� si lol \(::=c\\C)
V19i of Owner Date
SECTIOONN 77b: OWNER' OR AUTHORIZED AGENT DECLARATION
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
Frin Name
Signature of Owner or Authorized Agent Dat�T
(Signed under the pains and penalties ofu )
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
q1NON017,14
Z
iL TTS
CITY OF SALEM,, NLNSSACHUSF
DEPARTMENT OF PLANNING AND
COMMUNITY DEVELOPMENT
KnIBERLEY Diuscou_
MAYOR 120 WASHING TON S7niFa..r 01970
LYNN(-',(X)\tN J)t;\, cA_\',AICP TEIX.:978-619-5685 * FAX:978-740-0404
DIRECrOR
HOUSING Rt."HABILITATION LOAN PROGRA1\4
toccLfk),N w% ernr.
BID FORM of,
Property: 6 Buffum Street, Salem, MA Owner: Kantorosinski
WORK ITEM PRICE
I ELECTRICAL UPGRADES & REPAIRS $ 1_CS -000
2- SLATE ROOF & CHIMNEY REPAIRS $ \q "!Nw
3. PEST REMOVAL $ C'320
1"2 105-
TOTAL BID A 3Q_Q0____
1, the undersigned contractor, have inspected the above listed property and understand the extent and character
of the work to be completed as described in the Work Write-Up. The bid includes every item identified in the
Work Write-Up by the respective numbers- The bid shall remain in effect for a minimum of thirty (30)business
days after the bid opening.
I propose to furnish all labor, materials, and equipment necessary to accomplish all work
described in the Work Write-Up for the sum of
if � Q A:q , Octk)r tYh_1DDA2df)' - Wid Dollars ($34,9-0—
I would be able to start the project on 2010 (estimated date).
I agree to begin the work within fourteen (14) calendar days of the Notice to Proceed and complete the work
within sixty (60) calendar days of the Notice to Proceed. I agree to fully guarantee all labor and materials for
one 1) year from the project completion date.
V 10
Signature of Authorized Representative Name of Authorized Representative Date
JA:1c C
Company Name Address \k OYD-79 Telephone