22 BUTLER ST - BPA-12-156 Hie Conmioncve:dth of Massacltll5elts — _ __
Board of Building Regulations and Standards CITY OF
r :
Massachusetts State din Code, 78Zt,�Or
SALEAI
Building Permit Application To onstnict Repair, Recnwlish a
One-ur n o Finn' v Dw llin r
'r is Section Officia se OnI
Building Permit N tuber: at pplicd:
Building Official(Print Merle) Signature Dale
SECTION 1: SITE INFORMATION
1, IrrP�ro ty d�dr�s�\ t . n 1.2 Assessors Nlap& Parcel Numbers
I.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 It) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if cs0
p SECTION 2: PROPERTY OWNERSHIP' / n
near' W\ rtd• ScAA e'�i rn L711
N:un• riot '� City. ZIP
CT�m Qc>
No.and Street rciephone Email AddressC'oY✓1
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairsts) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Spceify:
Brief Delcription of Proposed Work':
r� X r� `1.16'12 L (7•r •�C`r r 'E;'Y� C t f j�
"Plunihings
ECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OfI7e1a1 Use Onl1 Labor and \laterialsl y
ing s I. Building Permit Fee: S Indicate how fee is determined:
ical s ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier_ _xing s 2. Other Fees: Sanical 1!I\':\CI s List:nical IFireionl 5 Total :\II Fees: Sr\��� C'hcck Vu. __('heck :\mount: _ _ asAntuunl:Project Cost: s d 0 Paid in Full O Outstanding Balance Due; - _ --
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Numher----- — hcpiration Date
N;une ul'l:Sl. I IulJer
Lint CST.1)pe Uec below)
No. :utd Arcot ---- ----- - -- - 7)•pe Description
U t Inrestricled I Ilui ldin ks up to 35,000 cu. It.)
R Restricted I r? Fmnil Dicdlin
Cit)lfown. State.ZIP NI Masonry
RC Rmling Cmerin
- W'S Window and Siding
SF Solid Fuel Duming Appliances
I Insulation
'I'cle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Expiration Dale
I IIC C'ompan) Name or I IIC Ilegislrant Name
No. mid Street Email address
City/Town. State, ZIP 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 of 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
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
y e tering my name below. I hereby attest under the pains and penalties of perjury that all of the information
font ined in this ppl' a�tion is true a d accurate to the best of my knowledge and understanding.
.
Print Owner's or: uthorizcd Agent's Name(Electronic Signa(ure) Dote
NOTES:
I. :\n Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under%LG.L.c. I43A.Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at dp,
?. When substantial work is planned, provide the information below;
Total fluor area(sq. ft.) (including garage, finished basement attics,decks or porch)
Gross living area(sq. it.) . . ` Habitable room count
Number of fireplaces- _ Number of bedrooms
Nuniher of bathroonis Number of half haths
1)pe of heating system Number of decks, porches
I)lie o(aiolings)stein _ 1'.11closed _Open
3. -I'ol:d Project Square Footage"ma) be substituted for'?otal Project Cost-
CITY OF SAI..E.Ni
PUBLIC PROPERTY
DEPARTMENT
wfa.arar out.aL
.%twee I30wASOmaromSMasr04,4llr %&.uAcwzrrtsaisle
7%L t'.11-745.7slf .VNL 978.7467w
HOMEOWNER LICENSE EXE.I4 MON
Please Print
Date as
Job Location a a S —
Home Owner Address
Home Owner Telephone
Present Mailing Addrew �v�5tMc
The current exemption of Homeowners"was extended to include ownQoccupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who don not posses@ a licenser provided that the owner act@ as supervisor.
DEF1NM0N OF HOMEOWNER
Persons) who owns a parcel of land on which he/she resides or intends to reside. on
which then is, or is intended to ber a one or two family dwelling, attached or detached
struchm accessory to such use and/or farm structure@, A person who constructa more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Oiliciat on a form acceptable to the Building
Otllcia4 that he/she be responsible for all such work performed under the Building
Permit
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undenigned "homeownee c A that he/she understands the City of Salem' .
Building Department minimum i on procedures and requirements and that he/she
,vill comply with said procedur and r uiremi
HOMEOWNERS SIGNATL
7.
APPROVAL OF BUILDING INSPECTOR _
Sce other side for state code
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