19 BUTLER ST - BPA-15-759 2— 0 ZS aD
The Commonwealth of Massachu F CITY OF
n Board of Building RegulatrIj��RyICES SALEM
Massachusetts State Buildi �+ Revised Mar 2011
Building Permit Application To Construct, i etlglklte Jar 6p"sh a
�Ut One-or Two-Familylk}j� L`t H
This Section For Official Use Only
Building Permit Number: Date Applied:
1
Building Official(Print Name) Signature Date
1 SECTION 1:SITE INFORMATION
^/ 1.1 Property Address:L � <� 1.2 Assessors Map&Parcel Numbers l la 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 ft) Frontage(11)
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? Municipal❑ On site disposal system ❑
Public❑ Private ElCheck if yes❑ P p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of cord:
Name(Print' � CiYy,State,
No.and Street Telephone Em '1 ddress
SECCTION 3:DESCRIPTION OF PROPOSED WORK(eheck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ .Repans(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brie�criptio��O�Propo�Sg�V✓orl��
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 Costa(Item 6)x multiplier x ,__
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Cheek No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description.
U I Unrestricted(Buildinas no to 35,000 cu.ft.
R I Restricted 1&2 Family Dwelling
City/Town,State,ZIP M I Masonry
RC I Roofing Covering
WS I Window and Siding
SF I Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street
Email address
City/Town,State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.g 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
co ' ed in this application is t e and acc ate to the best of my knowledge and understanding.
P ' wner's or Autho 'zed gent's ame lectronic rgnature) ate
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
wlvw.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dam
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"
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