36 BUFFUM ST - BPA-2010-187 1
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The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Ir� Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One- or Tyro-Fumilc Dmrlling moos
This Section For Official Use Only
B
uilding Permit Number: Date Applied: `
80d mg Commission/I sec uddings Date
ECTION 1: SITE INFORMATION
i.l Pro erty A dr ss: 1.2 Assessors Map dt Parcel Numbers
Y Ma Number Parcel Number
1.1 a Is this an accepted street'?yes_ no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(fl)
1.5 Building Setback (ft)
Front Yard
Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system 0
Public Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: ��^ --��"�-
f A ,1e Isd 41 13 b
Na (Print).
Address for Servi : Q
/ _
Signature Telep' one 7 7
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) ❑ Addition O
Demolition O Accessory Bldg.O Number of Units_, I Other ❑ Specify:
Brief Des ription of Proposed Work:
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building f I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical S 0 Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S T
4. .Mechanical (HVAC) S List: [/
5 .Mechanical (Fire S Total All Fees: S
"Su ression
Check No. _Check Amount: Cash Amdltnt:
6. Total Project Cost: S �„� � ❑ paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ) 844.C) :3 ?� 7&Q
"A5C- ' y, LiccnscNumbcr Expiration Date
N4roe of CSL- Helder n _ /J List CSL T ! '
,!j- IL.►}/Ly P p . r✓ILLEl2 Type lace below) y
Addre I s44- of z) T Description
\/ pyL�j s..�r�� U Unrestricted u to 73.000 Co. Ff I
(� R Restricted Ik2 Family Dwelling
Si n ure %1 I Mason Only
-7
RC Rcsdcnual Roofing Covenn
Telephone w5 Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 2.$6 '7 e47
(\ HIC Company Name or HIC Regisirant Name Registration Number
II A--SIC>06J r LAn.t �iVc� M'Iq . Ot _
Address _ t,.� ` I IS LOI 0
(PYyfp'N. � �sQ 6,7 Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 .......... O No........... O
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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of Owner Date
SE -T N 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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.
Print Name
Signature of Owner or Authorized-Agent Date
(Signed under the pains and penalties of peru
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 gl 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 he found in 780 CMR Regulations 110.116 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ff.) (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 halfbaths
Type of heating system Number ofdeckst porches
Type of cooling system Enclosed Open
t. "Total Project Square Footage"may be substituted for 'Total Project Cost"