B-17-947 - 0055 BUTLER STREET - Building Permit 13 2(P'(,,o _ -,�-s -
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
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 hPennrt Number' Date App'e
Bbildm Official Pnnt Name
`\ g ( ) Signature Date
T SECTIONI:SITE INFORMATION
1.1 Property Address: ` 1.2 Assessors Map&Parcel Numbers =�
N�r S� y ..
(� L l a Is this an accepted street?yes V no Map Number Parcel Number ' rnU f
1.3 Zoning Information: 1.4 Property Dimensions: -
i
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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2- PROPERTY.OWNERSHIP
2.1 Owner'of ecord:
-��5 -71r-r
Name(Print) City,State,ZIP
No.and Street Telephone Email Ad Mess
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ xisting Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) UTAddition ❑
Demolition afAccessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Descri do of Proposed Work2: 40 ro
rpom wv lie
gy c71
Gr C G
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials Y
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:$
��m yl Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ U U V ❑Paid in Full ❑Outstanding Balance Due:
c.q t_t r V-o rR-
°11% -a-la-E-(Om
L4M- ,
t
SECTION 5; CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) K
No.and Str et Type Description
��� Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
PP// _// I SF Solid Fuel Burning Appliances
q� "— JD� �� hirJ•011((nN/u/� I Insulation
Telephone Email address D Demolition
5.2 Registered Home I provement/Contractor HIC) r 7 6 ��
(,Oils u c /a� t— n HIC Registration Number Expiration Date
�T?m Name or HIC a istran ame
o.ayd�St4ee , _y'Cj DG Email address
City/Town,State,ZIP Telephone(O
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 Issuancol6f 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 Lt t e &� o
to act on y behalf,in all afters relative to work authorized by this building permit application.
Print Owne s Name(Electronic Signature) Date
SECTION 7b:OWNERS 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 applica ion is tru d accurate to the best of my knowledge and understanding.
Prin O er's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mass.¢ov/oca Information on the Construction Supervisor License can be found at www.mass. og v/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 halfibaths
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"
I