31 BUFFUM ST - BPA-14-143 Y 3- 6 -5 c�S�
- - � - e ommonwealth of Massachusetts
""0. y Board of Building Regulations and Standards CITY OF
Massachusetts State Build' Code,78 RECEIVED SALEM
a_ 4 CTIONAC SER S,d.,>-r�tl:_'
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Onl 14 y - .PR
- -
Building Permit Number: Date Applied:
Building Official(Print Name) Signature - to
SECTION 1:SITE INFORMATION
1.1 Proper Address: 1.2 Assessors Map&Parcel Numbers
�I IXJ Y _ Q N !S- 2"10014?
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(it)
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:
er
Public B Private❑ Zone: _ Outside Flood Zone? /
Check if yesL9� Municipal�"On site disposal system [I
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of Record:
GA(LzT' a t.yA2;i.�o SA(8'1 MA 019'1zi
Name(Print) City,State,ZI
31 i FFUH Si. 9Ta x1�-N3gi 1Awaf@V'arcr t t �S7
No.and Street Telephone Email Address-
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building mlOwner-Occupied Repairs(s) 0' Alteration(s) ❑ TAddition ❑
Demolition T1Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': per" y�R{,y h sn 2WIC-L- Pox)4 b.4c
12cVCAGs 'P02Cu A� ri �--
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only _
1.Building $ . 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ `❑Standard City/Town Application Fee -
❑Total Project Cost'(Item 6)x multiplier
- - 3.Plumbing $ 2. Other Fees: $ j
�-- — 4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
-_ Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ G 3�� ❑Paid in Full ❑Outstanding Balance Due:
`� 10 �--rnt7-rw)
WQD cry io Et wt:I3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) g, )� $_mot S
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masmiry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 jRReJgiistered Home Improvement Contractor(HIC)
'� )LL M - L\W M P 1 U HIC Registration Number Expiration Date
HIC Coma Name or HIC Registrant Name
(10
No.and Street
Kk )210'll MP. Oligt4L -1�(—�yLJ--Ll IS& Email address
t_
City/Town,State,ZIP Tel, hone
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...........O
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER[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(Elecnonic 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
www.mass. ovg_ /oca Information on the Construction Supervisor License can be found at www.mass.gov/des
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"