B-20-785 - 0010 BUTLER STREET - Building PermitY
The Commonwealth of Massachusetts
1 Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
(1 Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
-F�¢ .rrlas
Building Official(Print Name)S6 Signature Date
SECTION 1:SITE INFORMATION
(w �1.1 Pr a Address: 'r 1.2 Assessors Map&Parcel Numbers
1.1a s 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) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wn 'i f Record: , n1 f�
N10 e(Print) City,State,ZIP ' III !�
. B, ci .IL. &)_5 'K3_ 3gz( &86M 57766 qAacy3
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work 2: L
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:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
6�` � Check No. Check Amount: Cash Amount:
(D)nrojecl Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
JUL 30 P113=20
JUL
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder --
List CSL.Type(see below)'
_. •No.arid'Streef Type f
F - ~--•-- --- Unrestricted Buildin s:u o 35,000 cu.ft.,),
_.._ i U-�-,
R W - Restricted'1&2 FamilyDwelling
City/Town,State,ZIP NI Masonry,,. '
WS Window and Sidin-
SF Solid Fuel Burning Appliances'
I Insulation
Telephone Email address D Demolition ~
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
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 .......... ❑ . 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 _
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.
M l � z jig 12o
Print Owner's r Authorized Agent's Name(Elec •c Signature) ) Date
-T O"
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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/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"may be substituted for"Total Project Cost"
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OVEM LW OFFICE OF AMWJR P.Ste►Ur- BYE -
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
98 WASHINGTON STREET,2ND FLOOR
TEL: 978-745-9595
KIMBERLEY DRISCOLL
MAYOR
THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER
l
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION
HOME OWNER ADDRESS:
PRESENT MAILING ADDRESS: C5
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two(2)units or less and to
allow such homeowners to engage an individual for hire that does not possess a license,provided that the owner acts as
supervisor.
Definition of Homeowner:
Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a
ore-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A`06rso-h Vho
constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit
to the Building Official,on a form acceptable to the Building Official,that he/she be responsible for all such work performed
under the Building Permit.
The undersigned "homeowner"assumes the responsibility for compliance with the State Building Code and other applicable
by-laws and regulations.
The undersigned"homeowner"certifies that he/she understand the City of Salem Building Department minimum inspection
procedures and requirements and that he/she will comply with such procedures and requirements.
f�V�ll1
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR