22 BUTLER ST - BPA-11-678 CBuilding
The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7"edition OFSALEM
- Reviser/JmarrvPermit Application To Construct, Repair, Renovate Ur Demolish a(Jne-orTtvo-Fumily DwelUng.This Section For Official UseOnlr: 4 Date Applied: `
Signature: "u+i 3 10 /l
Building Commissioner/Ins tar of Buildings - Date
SECTION 1: SITE INFORMATION
1.1 Property Addrcg• 1.2 Assessors Map& Parcel Number
54
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dlmenslons:•
Zoning District Proposed Use .Lot Area(sq 11) - Frontage(It)
1.5 Building Setbacks(R)
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?
Public Private O- Check if es0 Municipal O On site disposal system O
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
A e eosin ham �a. 3�+� 5 �
Nome(Print) Address Service:
Gl/tvrlo C o. ^r q 7 S - -7 Y/ -8.510
Signature - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction Existing Building O Owner-Occupied O Repairs(s) O 1 Alteration(s) O Addition O
Demolition O 1 Accessory Bldg.❑ 1 Number of Units Other O Specily:
Brief Description of Proposed Work': ' r c5 ,-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OlflcInI Use:Only
Labor and Materials
1. Building s I. Building Permit Fee:s Indicate how.l'ee is determined-
0 Standard City/Town Application fee
2. Electrical s ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing s 2. Other Fees: S
4. Mechanical (HVAC) s List:
5. Mechanical (Fire S
Suppression) Total All Fees:s
Check No. Check Amount: Cash Amount:
6. Total Project Cost: 5 ���� Q� ❑Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervlsor(CSL)
License Number Expiration Dale
Name of C'SI.•I IulJo Eric,`- l List C'SL Type(see below)
'0 T.T:1 ,y i' .f Description �
AddressU Unrestricted u to 15,000 Cu. Ft.)
$a(Cf)1; R Restricted IR2 FamilyDwellin
Signature M M only
RC Residential Roofin Coverinst
Telephone WS Residential Window and Sidinst
—/7 - SF Residential Fuel Burning Appliance Installation
—[ D Residential Demolition t
5.2 Reglstered Home Improvement Contractor(HIC) /J2 o S-9
I IIC Company Nameor e s . 5�Lte Registration Number
61 R effzgcaAYentle 3//�-L/Z
nddrcaa '
Sal ein MA01970 �� -�Y'(-5�/-�i Expiration Dale
Sigrtaturc Telephone --
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 41) /Jc 00 y i1 ' r(a ✓f as Owner of the subject property hereby
authorize t to act on my behalf,in all matters
relative to work'authorized by this building permit application.
Sianaturc of Owner - Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT:DECLARATION
. —.a s Owner or Authorized'Agent hereby declare
that the statements and information on'the foregoing application are true and accurate;aothe best of my knowledge and
behalf.
Print Name S
Signature of/honer or Amhorized Agent Date
(Signed under the ainYand wliies of "u
NOTES:
1. An Owner who obtains a building permit todo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will ag have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing_(CSL)can be found in 790 CMR Regulations )I O.R6-and I IO.RS,respectively.
?: Whensubstantial work is planned,provide the information below: -
Total Roars area(Sq. Ft.) (including gunge, 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
1. "Total Project Square Footage"may be substituted for"Total Project Cost"