25 BUTLER ST - BPA-2009-374 � ! In �(D�tlrrLfb �—
The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code, 780 CAM 71a edition USE
a
B • Permit Appli lion Revised
Jdnuary I,2008
on o ffici se Only
n\ Building Permit Number: ate Ap iea-;' �- (r , d:a- C`b
\\
Signature: JC7' Ogj
Building Inspector Date
SECTION 1:SITE INFORMATION
Residential _ Commercial ❑ , Other Description:
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Lla 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 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? Municipal❑ On site disposal system ❑
Commercial- Service Size Checkifyes❑,
SECTION 2: PROPERTY OWNERSHW
2.1 Owner'of Record:
Name riot 3 �7 a
(P Address for Service:
Igoe Telephone ..
SECTION 3:DESCRIPTION OF PROPOSED WORle(check all nt apply)
New Construction ❑ Existing Building❑ Owner-Occupied Repairs(s) Alteratiou'(s) ❑ Addition ❑
bemolition= - ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Wo k`:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) y
L Building $&ai 06& r 1. Building Permit Fee: $
I 2.Electrical $ 2. Indicate how fee is determined:
3 a ❑Standard CiVrown Application Fee
7 3.Plumbing $ ❑Total Project Cost'(Item p� (1 6)x multiplier x
-� 4.Mechanical (FIVAC) $ 3. Other Fees: $
J� y 5.Mechanical $ List:
l 5 (Fire Suppression)
ova ci Total All Fees:$
6.Total Project Cost: $ 3,q , 000 ' Check No. Check Amount: Cash Amount:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor/(CSL) mry
ada,d o-- License Number Expipbdonl) to
e7 of CSL-Holder List CSL Type(see below) a.
N
/7 of ic7
Addressess Type Description
U Unrestricted(up to 35,000 Cu.FL)
R Restricted I&2 FamilyDwelling
Signature, r/ M Masonryonly
G s T 6 RC Residential Roofing Covering
Telephone, WS ` Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 egistered H me ly rov ent ntracto (HIC) m
HIC Company Name or HIC Registrant N Registration NtUnber
ddryss /� p
x uoti Date
-Signature relepk6ne
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit mast be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the b ' ' permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, �D�-!/1 as Owner of the subject property hereby
authorize CV - .7 On G a P to act on my behalf in all matters
relative to work authorized by this building permit app ication.
i a of Owner: Date t,
// SECTION 7b: OWN`E`R' OR AUTHORIZED_AGENT:DECLARATION
as Owner or Authorized Agent hereby declare that S
the statements d information on the foregoing applica on are true and accurate,to the best of my knowledge and behalf
Print Name
"Signature of O er or Date
(Signed under The pains and penalties of perjury)
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 tinder M.G.L.c. 142A.Other important information on the HIC Program and Construction
Supervisor Licensing(CSL)can be found in 780 CMR Regulations I MR6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
i
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 haWbaths
Type of heating system Number of decks/porches _a
Type of cooling system Enclosed Open