19 BUTLER ST - BPA-2012-950 7 the Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
st y, Massachusetts State Building Code. 780(WR S.\LfA1
Building Permit Application To Construct. Rcpair. Renovate Or Demolish a
Uuc•ur rue-family Unelliu•Ar
This Section For Olreiol Use Only
Building Permit Number. Date pplied:
Building OBicial(Print Nwne) Sigrtoture Dal
SECTION I:SITE INFORNIATION
L I Pro�r y AIIsJ�esp:�Q� st 1.2.Assessors blop di Parcel Numbers
I.la Is this an accepted street? es no Nap Number Parcel Number
1.3 Zoning information: • 1.4 Property Dimensions:
Zoning District I'n+poscd tlso Lill Area(sq II) Frontage(II)
1.3 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required provided Required Provided Required Provided
1.6 Water Supply:(M.G.].e.aU,§s{) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public private❑ Zane: _ Outside Flood"Luna? �/
Check if yes❑ Municipal(d On site disposal s)stern ❑
SECTION2: PROPERTYOWNERSHIPr 7
"Construction
o ! 0
('igtStatc.I.IPrelep unB a Email Address
CTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
Existing But
❑ cupiedX1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Spccit'y:
Brief Description of Proposed Work':
SECTION J: ESTIJIATED C . STRUCTION COSTS
Item Estimated Costs:
(Labor and.kluerials) Official Use Only
I. building 5 I. Building Permit Fee: S htdfcate how fee is determined:
2. Fieciricai 5 ❑Standard City:Tosvn Application Fee
❑Total Project Cost'l Item 6)x multiplier
I'lunihing S 1
Usher Fees: S -- —
J, \lahanical illl'.1(') 5 List: / .
\u�+ftESionl S Tulal \Il Fees: $_ ____
1� C11"k \'u. ('heck:\m+mnC C,uh \momu:
o Total Project Cost: 'S OL 0
❑PaiJ in Ftdl -- ❑lhnstanding Balance Due:
SE( I ION 5: CON5 I'MicrION SF.RVI('FS
5.1 C'unstruction Supervisor License(C'SL)
I I Kite
N.,111c I lnldcrI CSL I.)IV("Cc 1161%k)
PC Description
No. aid Strect I I Itirestrictcd I Buildin 13 0 to 31-11(10 01 11
It Itc.,iricted M2 Famil MwIli"
Citsiklmi.SIAV./11' %1 Nlasoll
RC R,xflin Co%crili
AS Window.aid Sidin
SF solid Fuel Burning Appliances
I Insulation
I c1cpholic 1(niail addrvNs D Denxllitiun
5.2 Registered Home Improvement Contractor(HIC)
IlIC l(cit6tralicin Number Expirlition Date
I IIC Compan) Name or I IIC Regisirant Name
No. and Street Email address
City/Town.State,ZIP Rlc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.J 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 ..........Cl No...........0
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 Usurer's Nurne(Electronic Signature) Date
SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contain k'Ithis application is true and accurate pt the best of my knowledge and understanding.
J
Print 11% lvvtkilnic ii4liaturc) ate
NOTES:
A n 70%%ner who obtains ibuilding permit to do his,her own work,or an owner%0o hires in unregistered contractor
I c u I not registered in the Hume Improvement Contractor IHIC) Program).will aa) have access to the arbitration
) 'u 'I
program or guaranty rand under.M.G.L.v. 142.A.Other important information on the HIC Program can be found at
�0% Information an the Construction Supervisor License can be round at�%%k�% nm,; '!11,
When substantial work is planned,provide the information below:
our
rotal illoorarcitiq, R garage, rinishcd basement attics.decks or porch)
Habitable rouni count
I \umhvr of fireph"s Number of bedrooms
'Numherol'Jecks, liordics
I"%I'v"I'coollog sicill Inclosed
I lolal Proiccl Square rootage" be uhNimacd IlorI*,11al Project Coif"