22 BUTLER ST - BPA-11-784 fl
The Commonwealth of Massachusetts
QUI
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALERevised L ar420//
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tw a ily Dwelling
This ction f or Official Use Only-
Building Permit Nug er: -Date App ' z;/
Building Official(Print N Signature Dale
SECTION I:SITE INFORMATION
1MeM(A)d dress: 1.2 Assessors Map& Parcel Numbers
yf1
L la Is this an accepted street?ye uo Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water S p :(M.G.L a 40,§§ 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ vat i� U N? eid ,Floodfyes[ Municipal ❑ On site disposal system ❑
SE TION 2: PROPERTY OWNERSHIP'
2.1 ,�, i of
Nm Print (� State,ZIP '✓t' l I
e 7D
No.mid Street "Telephone Emad AfddfessY
SECTION 3: DESCRIPTION-f`OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief De iption of Proposed Work':
3L-r (�e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and at ials
I. Building $ 'AOUU 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:����
Mechanical (Fire $
r6.uT
ression) Total All Fees:$
lr� Q6 O Check No. Check Amount: Cash Amount:
otal Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Typc(see below)
No. and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Fown,State,ZIP M Masonry
RC Rooting Covering
WS Window.md Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
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 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
1,as Owner of e subj t)ma,
e ,hereb authori
to c[ y eh If,in IIe s elativ w t his building permit application, l
/
Prin wner's Name(Ele ro 'c Signa u ate
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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner'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
%v%vw.masa�,ov%oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"