23 BUFFUM ST - BPA-12-318 T
The Commonwealth of Massachusetts --- -
�; � Board of Building Regulations and Standards CITY 1 OF
Massachusetts State Building Code, 780 CMR SALEM
Krri.rrd.l Jcu�_0!l
`) 1 Building Permit Application To Construct, Repair, Renovate Or Denwlish a
�' DV One-or Ttvo-Funnily Dwell ttlr
This Section For cial Us nl
Building Permit Number: ate ADDliedii
Building Olficial(Print Namc) S'gnature Dole
SECTION I: SITE INF` RMATIO
I.1 Property Address: 1.2 Assessors` lap Parcel Numbers
JrJ
L I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.3 Property imensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(I1)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check ifycs❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Gh'- i1:,1"? !'sjt 0lalla
N;une(Print) City,State,ZIP
3 07-0-7793
No. and Street 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': i.& T/.UD'L
VI G., V 'trh-✓lT—C 'amr
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and \laterials) Official Use Only
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
_. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing S 2. Other Fees: $ �
a. Mecli,\Icchanical 01\':\C) $ List:_
5. Mechanical (Fire $ —
Suppression) Total All Fens: $
Check No. Check Amount: Cash :\mount:______
6. Total Project Cost: $ f/d 0 Paid in Full 0 Outstanding Balance Due:
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
I.icense Number Expiration Date
Noma olY SI. I folder 6 a
� List CSI. fypc Iscc helou7
N). and Street fype Description
SQ/C � d/A 7� U Unrestricted IBuilJin u' 35.000 ca. 11.)
R I Restricted IK2 Fantil Dwelling
Otyi futw.Stale.ZIP M Masonry
RC Roofing Covcrin
W'S Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'I'cle hone ('.mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
—M , B ebq mil, fiGh(f➢"va�ru�J I IIC Keegi_sltrati, Number F.vpir,aion Date
I IIC Company N;une or I IIC Registrant Name
;14 Rc,1ItGf,i
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 .......... M' No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize M. Q/+ "� _
to act on my behalf,in all matters relative to work authorized by this building permit application.
Yyllivl
Print Owncr's Name(Electronic Signature) Dale
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 Ottner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his,fier own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to(he arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
uww.nut>,.L;.w oca Information on the Construction Supervisor License can be found at t��}��,nu) >.g�,� Up;
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) I including garage, finished basemenCattics,decks or porch)
Gross living area(sq. 11.) _ Habitable room count
\umber of fireplaces — Number of bedrooms
Numher of bathrooms Number of halfbaths
---------------- -------------------
1'y pe ofheating system _ Number of decks,-porches
1)peo(autling s}stem Enclosed
3. "Total Project Square Footage-stay be Substituted for''fotal Project Cost"