24 BUFFUM ST - BPA-2009-460 The Commonwealth of Massachusetts
J ; / Board of Building Regulations and Standards TOE
Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fantily Dwelling
This Sectioji,116 Otli ial Use Only
Building Permit Nu er: D to pplied: q
Signature: lb�
Building Commissioner/Inspect r of Buildin Date
ECT ITE INFORMATION
1 ay erJ,y y
Address; 1.2 Assessors 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 R) 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: ,1 ( , — ^ l f ,n U, , ,
Name(Print) Address for Service:
Signature Telephone !I
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑TExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed
1 Liu p o
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: 4 3 r
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
.Total Project Cost: $ �, 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date r '
Name of CSL- Holder d List CSL Type(see below)
—L T Descri tion
Addres , .
J U Unrestricted u to 35,000 Cu. Ft.)
R Restricted 1&2 Famil Dwellin
Signature M Mason Onl
RC Residential Roofin Co,
Telephone ^ ll-�. WS Residential Window and Sidin
�J d SF Residential Solid Fuel Burnin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 t —7(0 �1, �1
HIC Com n Name or IC R�gtstr tamci,, Registration Number`
Address r � /b�V J L I
F-�' I / � Expiration Dale
Signature M
Telephone 1.1
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 PERMIT
1, 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.
Signature of Owner Date
KTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I ,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. ( ^ 1 Print Nam (r�,�L.W� y'J �
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury
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 I I O.R6 and I IO.RS, respectively.
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"may be substituted for"Total Project Cost"