21 BUTLER ST - BPA-2010-800 Q)C^ Town of
The Commonwealth of Massachusclts
Uig
Board of Building Regulations rnd Standards ��
� Massachusetts State Budding Code, 780 CMR. Ta edition Building Dept
(�� \ BuildingPermit Application To Construct. Repair, Renovate Or Demolish a RL'�
�J�1One-or Tits-Funuh Du ellmg
This Section For Official Use Only
Budder, / Date Applied:Signa """" -mission/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
I Pr /�� 1.2 Assessors Map dt Parcel Numbers
1.Is 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(k) Frontage III)
1.3 Building Setbacks(fl)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:I c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
_
Public O Priva O Check if s0 P Muniei al O On site disposal system O
te
SECTION 2: PROPERTY OWNERSHIP'
.10 �'of,Record:
G �j 4 L
Na Pr' t) Address for Service:
• tore Teleph v
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building 0 Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O Accessory Bldg. O Number of Units_ Other O Specify:
Brief Description of Proposed Work':
"It S v
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllclal Use Only
Item Labor and Materials
1. Building f I. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2 El e incal S O Total Project Cost'(Item 6)x multiplier x
7 Plumbing S 2. Other Fees: f
a. Mechanical (HVAC) S List:
--
I Mechanical (Fire S Total All Fees. S
Su ression
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S 04 ov. 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
!.I Licensed Coas ruction/Supers is r(CSL) 7/—�� 7 �/ /O -
" �)��• 72 �G/ �// 76-1� Li.cese.Vumber E.pi/nnonDate
Nytieut CSL- fyl er Li,i CSL Type(uv tic-low) 11-1
r Descri lion
A sf
U Unrestricted(up to 33,000 Cu. Ft.
R Restricted l h2 Family D%ellm
Signature p 3 Masonry Onl
RC Rcvdential Roofin Coverin
Telephone w'S Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered H me pprov real Contractor(HIC) /� / kSL/
) /, C o en Fu
HIC Company N or HIC egisirant Nam elpstrall Numbe
ov o C �C/ehl� 7 d 8
Add p
9�0 7 y s=L-3i 3 Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.f 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 ci ilding permit.
Signed Affidavit Attached? Yes.......... No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
d 1, as Owner of the subject property hereby
aujhoriu to act on my behalf,in all matters
relative to work authoTthisermit application.
Si alum of Owner Date
SECTIO/N 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, s�� C L e �4 �f—_ ,as Owner or Authorized Agent hereby declare
that the statements and info at�the foregoing application are true and accurate,to the best of my knowledge and
behalf. /
Print Name
Signature of Owner or Authorized Agent Date
Si ned under the esins and penalties ofperjury)
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110 R7. respectively.
2. When substantial work is planned, provide the mfonnanon below -
Tota( Moors area ISq. Ft.) (including garage, finished basementlanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Numberofbathrooms Number ofhalfbaths
Tvpe of heating system `lumber of decks/ porches
Typeof cooling system Enclosed Open
1 "Total Project Square Footage" may he suhslituied for 'Total Proiccr Cost"
The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7th edition ALEM
ReOF S January
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This`Secttoh;For Officta) se Only"
Building Permit Number: ' Date Applied ':
'Signature, -
Buildiug,Conimissioned Ins- tot of B6ildmgs `Date'; "- -
14,SITEFORIVIATION IN
1.1 G Property Rad�ev Z 6 -3
_,3 1.2 Assessors Map& Parcel Numbers
L la Is this an ac ted 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?
Check if yes❑ Municipal❑ On site disposal system ❑
c=SECTION 3 PROPERTY.OWNERSHIP2�-
2.1 Owner ofJtecord: / / 6D j L �_
Name(Print) z Address for Service: '
Signature Telephone
SECTION 3i I)ES,CRIPTION OF PROPOSED WORK'(check all that apply)'
_�.. .
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repalrs(s) ❑ -Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
- STi4�� � ��2 5 r• /l/G�y -
40
SECTION 4: ESTIMATED:CONSTRUCTIONCOSTS .
Item Estimated Costs: Official Use Only,
Labor and Materials
1.Building $ 1 Building Permit Fee $ <' " = 'Inilicatehowfee=is determined:
2.Electrical $ ❑Staudatd City/Town-Applicatiou-Fee,-
❑Total Protect Co§t'(Item 4)•x'multiplier Xr.
3.Plumbing $ 2 OtherFees $
4.Mechanical (HVAC)
5.Mechanical (Fire
Su ression) $ Toisl All-Tees $
Check No m Check Aount., Cash Amount:
6.Total Project Cost: $
a Gv- ❑Paid in Full ❑ Outstanding Balance Due:
SECTIONS: CONS TRUCTION,SERYIGES
5.1 Licensed Construction Supervisor(CSL)
M (C 2 e L License Number Expiration Date
Name of CSL-Holder (/
List CSL Type(see below) ..
Address n n n I—D
% Description
Restricted 1&2 FamilyDwelling
Signature (�/ MasonryOnly
Residential RoofingCovering
Telephone Residential Window and Siding
Residential Solid Fuel Burning Appliance Installation
Residential Demolition
5.2 Re istere H e I provement Contra for IC)
HIC Co Name or C Reg •tttt ne Registration Number
Address�/7/��� / r —�
. 7Glf�q 7i 13 Expiration Date
Signature % Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE,AFFIDA�'IT(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 7i:OWNERtAUTHORIZATION-TO�BE'COMPLETED WHEN,, ,
OWNER'SAGENT OR CONTRACTOR APPLIES FOR RUH;DING P.ERMTP
I, as Owner of the subject property hereby
authorize 11- to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECCTION 76:,O iWN/E/R'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
L
Print Name i
Signature of Owner or Authorized Agent Date
(,Signed under the pains and penalties of r'u
- 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 and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 IO.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"