15 BUFFUM ST - BUILDING INSPECTION �s� °�
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�, The Commonwealth of Massachusetts REC
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Board of Building Regulations and Standards INSPEG IONMICE
Massachusetts State Building Code, 780 CMR
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish JUN -4 P 12- a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date App ' d:
,. f
Building Official(Print Name) '� "' N-' Signature a Da e
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
15 AUFFI.IIYI .�Z
LIn 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) L7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2::PROPERTY OWNERSHIP'
2.1 O er f]tecord:
\/OL-A $13IF_Yv1 /Ylp, O/ 9 70
Name(Pn qt) City,State,ZIP
Is sus=r- um 5>•, 61 ?- 791-1-953
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building 03' Owner-Occupied 12 1 Repairs(s) 2"' Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
9DZiP /-)ND ROo,� iti7-h CEl 77+rNrEFD Larvnrna !C ARAN /FC7-
4/7tr!</FS
P ,
zF 2t' ✓F r=i/Y uc h-D- p igbo bod,'C T-1 P5k94olDg /1119,
ta x�SECTION 4:ESTIMATED CONSTRUCTION COSTS ,,1 - - i7r
Estimated Costs:
Item Official Use Only
Labor and Materials c n "t
1. Building $ (�(�02 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee s
2. Electrical $ p' f °z
❑Total Project Cost'(Item 6)x multiplier x-
3.Plumbing $ 2. Other Fees: $
4. Mechanical (1-IVAC) $ List . '
5. Mechanical (Fire Su ssion
$ Total All Fees:$
re
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �r L 00/ ❑Paid in Full ❑Outstanding Balance Due:
MAIL TLj c, CMAtLCQ 1p (C1
SECTIONS::CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
3 -o2,)/S
N2.RN h �/, /QUO✓.E License Number Expiration Date
Name�f CSL Holder
List CSL Type(see below) g_(f
SN P/a �77uck zFiNE
No.and Street Type_ Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
/T R Restricted I&2 FamilyDwelling
CityfF Sta M Masonry
RC - Roofing Covering
W S Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
RRIPA RLiRKF 21dFlNL 7d7/�� -a i at
HIC oal any Name or HIC Registrant Name HIC Registration Number Expiration Date
.17 /.-f/2oN sr 2Cr_ 7-
No.and Street Email address
_1dAlfFFIEId, /Yy /q 4 / Ep-D 7EIJVS///0
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 .......... L9 No........... ❑
SECTION 7ai OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize 2A I p ki QU 2K_F RodFl N6
to act o my half,in all matters relative to work authorized by this building permit application.
Print my'
Name(Electronic Signature) Date
SECTION 7b:'OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below,I . by attest der the pains and penalties of perjury that all of the information
contained in this application rue d �u�raato the best of my knowledge and understanding.
Iw ti 6U2ue
Print Owner's or Autho A e is ame( lectronic 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..00v/oca Information on the Construction Supervisor License can be found at wD w.mass.¢ov/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"maybe substituted for"Total Project Cost" /(r S C,�