6 BUFFUM ST - BPA-2010-925 V The Commonwealth of Massachusetts
Lei Board of Building Regulations and Standards CITY
J Massachusetts State BuildingCode 780 C 7 h edition OF SALEM
MR
Remsed January
Building Pennit Application To Construct, Repair,Renovate Or Demolish a 1,2008
One-or Two-Family Dwelling
-This Section For Official Use Only - -
Building Permit Number: - Date Applied: -
1 `
Signature: t7�'IiI/ C7
Building Commissioner In - Date -
Sf C 1:SITE INFORMATION
1.1 PMdd ess: c 1.2 Assessors Map&Parcel Numbers
L la Is this an accepted street?yes_ itT o Map Number Parcel Number
13 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 OWNERSIIIP'
7Z'1�Owner'of Record: t�
` �boc�4�Vr�c�cc,.� '�OcOS�hS�. \10
Name(Print) �9 Address for Service:
4'Signature.- Telephone
SECTION 3(DESCRIPTION OF PROPOSED WORIe(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 2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials � -
1.Building $ �O4�W 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: $ �'�,Q� . 0 paid in Full 13 Outstanding Balance Due:-
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor CSL
License Number Expiration Date
Name of CSL-Holder '
List CSL Type(see below)
Address , \ Type Description
U Unrestricted(up to 35,000 Co.Ft
R Restricted 1&2 Family Dwelling
rgrratur M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIQ Registrant Name El Registration Number
Address
Expiration Date
Telephone
SECTION 6:WORKERS' OMPENSATTON INSURANCE AFFIDAVIT(M.G.L.Ic. 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 ..........aB No...........❑
SECTION 79:OWNER AUTHORIZATION TOBE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�OS�rS�� as Owner of the subject property hereby
authorize \l�l�\ Vl�i>` to act on my behalf,in all matters
relative to work authorized�by this building permit applica on.
S, �/. /
i Signature of Owners fiBate. _F
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
I, S ,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
w
Signature wn r or Authorized Agent
TgiftdMder the pains and penalties of
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 110.R6 and I10.R5,respectively. I,
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"maybe substituted for"Total Project Cost"