31 BUTLER ST - BPA-13-293 /5
I'hc Cbmnnollweallll of Massachusells
' r hoard ut Building Regulations and Sf;mdards CI'i'Y OF
s?L . NiassachlisvIts Stale Building Cudc. 79U CNIR SALEm
+�\ Building Pcrnail Appiieatiom To Construct. Repair, Itcmuvatc Or De Rero"d Ilar:n//
:hre-Or rm•rr•flamir Dn ellim,p u
This Section Fur Olfi .Use Onl
Building Permit Number.
D e Applied: p
IT..IdlnyOR)dal(PrintN;unv) / 7
Sigtsaturc I)olr
SECTION is SITE INFORNIATI
I.I Property Js resit
�� ( 1.2 Assessor Slap& parcel Number
I.la Is this an acre led street? es no Ninp Nunsher I'urcel Numhrr
I.! Zoning Information: 1.4 Property Dimensions:
riming District I'mposcJ(1j
Lot Ana, ..It) Frsnstaya(tl)
1.,1 Building Setbacks(R)
Fran:Yard Site Yards
liver Yard
Rryuircd I'ruviJcd Required ProvidedNryuircd Provided
1.6 Water Supply:111 41.c.40, §)y) 1.7 Flood Zone Informations La Sewa`e Disposal System:
I'u Clllc Pricato❑ Zone: _ Outside Flood Zone?
Check iY esp Municipal❑ Dn site disposal s)stem ❑
SECTION2. PROPERTY OWNERSHIP'
2.1 OW tfs7sgfR r -�
IN all P
Ciq.Stata.ZIP
No.and Street
7V-" h
Yelrphane Email AJdrcss
SECTION J: DESCRIPTION OF PROPO
SED IVORK c
New Construction❑ Existing Building❑ Osvner•Oceupied ❑ Repairs(s)heek al�l1fe that
pP"1❑ Addition O
Demolition ❑ Accessory Bldy.❑ Numberof Units
Brief Description Of Proposed Wmka: Other O .Spreity;
SECTION 4: ESTIMATED CONSTRUCTION COSTS
liana Estinsaled Costs:
I1.abor mad\Luerials) OM NI Use Only
I. Building S I. BuiWiny Permil Fee: S Indicate how tee is determined:
Iacctrical $ ❑Standard CityrTuwn Appllcaiion Fee
I I'lunihiilg S ❑Total Project CuslI I Items 6).x multiplier x
'. Olher Fees: S --
1. \Icda.mic.al ill\ List: /•�) j�
Cu nisiona rotai lR Fccs. S
n 1'ural Prmjivct Cnst f eil � 11 .%k \'o. _( heck.\nnnnq: , l'.i h \rerun:
TO 0 P.iiJ m Full OulsrwJiny B,il.mce Due:
SF.('l ION S: ('t)IVtiI'R11("fl(TNSERYI('ES �j J
structimtSuprniiurLi urlC'St.)
.. p,,Iralinu I)llle
Ntinlhcr I
Nat Ic III,
7 Dcicriplinn
14o. .IIIJsIr.. li 141nslridcJllhulJini tu1t,1111tlNl. 11,)
TO P,unil) m%yllilill
C il)i Poe n,tilele,Lll' NC Nl,ldin l'uwrin
µ S µ'indue'.wJ sidill
SF Soli)fuel burning Appliances
2 J (✓, I Insuloliun
1'dc hone
14nalt uJJre+s U Drnu,liliun
3,2 Re flared Ilume Ingsrw'rn el t Cunfrnetor(IIIC) Itegleu;aion Numher P.,pinuiao Will
UIC'C'um in) Name I C ay sou t `nu
limull addfris
No. and 5
Ci hone!town.Slate ZIP
Ill iSC(ti))
SECTION 6t WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 133.I
this application. Failure to provide
Workers Compensation Insurance affidavit must be completed and s omitted with
this affidavit will result in the denial of the Issuance of the buildingp
er
Signed Affidavit Attached? Yes N0 I]
SECTION 7a:OWNER AUTHORIZATION TO BE CODIPLETED W HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERhII
I, as Owner of the subject property,hereby authorized
to act on my behalf,in all matters relative to work authorized by this building Permit application.
n Ki `/ Duta
Print U,wer'f Nwne lE cewnic Signulunt)
CLARATIO
SECTION 7b:OWNERI OR AUTHORIZED AGENT DEN
B hereby
he pains and penalties or perjury hat all of
o stained ini this applica on is true attest ndaccur tee t to he best army knowledge and understanding.t informal
' note
I'fill!QHne�iOr:\IIIIIUrI/edr\`ellli NIIIIW IlileClrpllll'..\IgI1NVQ fESt
registered
we
I. An registered iobh iIl$ 3 b hnpruPrmenttCummctur II�ICI pragromLn allnur shave access tolhe arbitration llractur
orm
Prog`am of guar n tyl ulld 1 wn an he CuostructionhSuer penv sor Li eilliportant lnse can be found at
lion on the C Program can be round al
µ!ten subilamial,wrk is Pl:um rug idle the inf'unnatiun below:eJ, p 1 htcluding garage, finished basentrnt attics,docks or Porcltl
Total flour area 14 tt.) . ----"— 1hlbitablle roual count
Groii li%iog arra l iy, ll.) Numher of hedruoms
\unlheraf fireplaces .. ... _ Nunlbendhol .hmlli .
�11111Her,,1 h:11I1rlJllli - Nllillher„l decks porJ10
I of hc.uing i)+lain Inclosed
I IN„I' edam
1 "lol.11 I'nitelt \,ln;IfC I',ho•Ige Ilta1 hC •uh,liuncJ ILr"I',Il,d I'rl�ject Cn,i'