11 BUFFUM ST - BPA-11-803 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
U Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Off ' 1 Use Only
Building Permit Number: D e Applied:
_ 1 ho",73 T Sf�,���P -
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.I Frop� y Address: �.� ^ _J- 1.2 Assessors Map& Parcel Numbers
/l Y rKt�r-
1.1 a 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 R) Frontage Ul)
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 OWNERSHIP'
2.1 Owner'of Record: i
J r.Vs61�a
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
ief Description of Proposed Work': c`.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $
❑Standard City/Town Application Fee
❑Total Project Cost'(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: $ 10 f 0Go ❑ paid in Full ❑Outstanding Balance Due:
ti;� -fD
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 64
B,
_ :7-74- 1. License Number Es iratin Date G'Z
Name of CSL Holder
t, p�� List CSL Type(see below)
No.and Street U`J yJ� Type Description
Unrestricted(Buildings u2 to 35,000 cu. ft.)
Restricted 1&2 Family Dwelling
City/town,State,ZIP 7RCE
Mason
av Roofin CoverinWindow and Siding
r7 �J SF Solid Fuel Burning Appliances
l-7 2r 7 �74'/ 1 Insulation
Telephone Email address D Demolition
5.2 Registered Flome Improve�meenttt Contractor(HIC) ,yty ZCo 9
� L
—` - - " "' f IC Registration Number Expii.tiun!)ate
HIC Company Name or HIC Registrant Name
No.and Street 9-1 ' /
W UC Email address
City/Town, State,ZIP
SECTION 6:WORKERS'C61M NSATTON NCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit 'us a ed and submitted with this application. Failure to provide
this affidavit will result in IFfg nia of the ss -o the building permit.
Signed Affidavit Attached? No........... ❑
SE TION 7a: O A T ORIZATION TO BE COMPLETED WHEN
NEI AGE V OR ONTRAACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize to act on my behalf, in/all matters relative to work authorized by this building permit application.
Prin Owner's Name(Electronic Signature) / ate
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:
I. 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
wwxv.mass.-,ovioca Information on the Construction Supervisor License can be found at www.niass.eoy/dps
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"