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11 BUFFUM ST - BPA-13-627 The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY O Massachusetts State Building Code, 780 CMR SALM Revised.E 2011 J Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Dat Applied: Building Official(Print Name) / Signature /Date SECTION 1•SITE My ON 1.1 Pro erty Address: . Ass ors Map&Parcel Numbers L l 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 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? Check if yes❑ Municipal On site disposal system El SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownyr'of,te%, '7V Sri: tin �-Mn So Q-ee� ko 14• biq 1 O Name(Print) - City,Stale,ZIP i\ f3c� sk k�8 - S4�!-f�y66 Ve+-yto-A JD6tm h6 a,`�, Coves o.and Sheet Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Buildin Owner-Occupied Repairs(s) ❑ 1 Alteration(s) P�- Addition ❑ Demolition Al Accessory Bldg.11 NumberofUnits I I Other [(-Specify: Ife U -VJ rlf. 9cLM1 Gool-I Brief Description of Proposed Work': , u t(a_ N e.vV ci/ ✓1 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: ❑Standard City/Town Application Fee 2. Electrical $ ❑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: $ 0 Paid in Full 0 Outstanding Balance Due: I SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) io1-740 2[�l� ���yla�„r �1.lo vJ�V �� S License Number Expira�on✓D�te Name of CSL Holder U List CSL Type(see below) 5 P,'vt-e S� No.and Street Type Description &01'�V 1 � 'n ©� ty U Unrestricted(Buildings u to 35,000 cu.ft. dy ' /T 1 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding t_ SF Solid Fuel Burning Appliances 0.Mov 'TSC�JOi-S I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement/Contractor(HIC) 1 .7 A LA I Z ZOI y A{'lS( fsp—u4$ Ii"4e- 1"44071VA--Q�SVC-S • HIC Registration Number Expir- anon Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP 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 , R PE 7MIT I,as Owner of the subject property,hereby authorize /-st2Xcrvt�2�' ftU S , to S to act on my behalf,in all matters relative to work authorized by this building permit application. I�/ -Tus-kl ki" V"-V tc1tl e-, q r,�� 1 Zo t l Print Owner's Name(Electronic Signature) CC--%-L+rt c l Date 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. Printer or Authorized Agent's Name(Electronic Signature) Date 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 can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns 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" �CbPO� �Gu '� a'Y� IoG(G `CSi� � ��� � S-P �-C� c� I _�` � I Q � Ill� �`� I .. -- _ -_ CITY OF SM EM, NViSSACHUSETTS Bt:II.DING DEPAItT%MNT • 120 WASHINGTON STREET, r FLOOR TEL (978)745-9595 FAX(978)740-9846 KIMBERLEY DRISCOLL T MAYOR ttonus ST.PffRRB DIRECTOR OF PUBLIC PROPERTY/BL'I1DING COMMMIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busim-ssiOrganizatioNlndividtW): —PKfI Vt d rnoiV" \tea/ `0ZS Address: CL P s M—, City/State/Zip:Pz,0.�d f-W 4 b i 9 6,6 Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.�1 am a sole proprietor or partner- listed on the attached sheet: 7. ❑Remodeling ship and have no employees These sub-contractors have $. ❑Demolition working for me in any capacity, workers'comp.insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 1013 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL )1.❑Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees.[No workers 13.❑Other comp. insurance required.] J I •Any applicant that ehacks box 81 must also fin cut the seciieo bclowshowing their workem'compensation policy information. t I(omeawnen who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such =Cutnm"m that check this bex must anachod an additional sheet showing the nmne of en subs mmeton and their wotkem'comp.policy information l am an employer that Is providing workers'compensadon Insurance jar my employees. Below is the policy and Jab site information. Insurance Company Name: _ I Policy#or Self ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the worker'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this staa:mcm may be forwarded to the Office of Investigations orthe DIA for insurance coverage verification. do hereby certify under t e pains and penaties ofperJury that the information provided above Is true and correct. A Signature: Date- Z Il �Zo i Phone Official use only. Do nor write in this area,to he completed by city or town of kiat City or Town: Permit(I.Icense# Issuing Authority(circle one): 1.Board of Ifeallh 2.Building Department 3,Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person' Phone#: i CITY OF Si .E:N1, 2LXSSACHUSETTS • BuaDLNG DEPARTNIE.vT 130 WASHNGTON STREET, 3"0 FLOOR 'ICI_ (978) 745-9595 FAY(978) 740-9846 K1�t8ERI..EY DRISCOLL MAYOR THomm ST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUMDING COMNUSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c l 11, S 150A. The debris will be transported by: / (name of hauler) The debriswill be disposed of in (name of facility) S wL44 l CL d (address of facility) signature of permit applicant Z�2 f2o, y date