51 BUTLER ST - BPA-11-352 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, Vh edition OF SALEM
Revised January
Building Permit Application To C tract, Repair, Ren vate Or Demolish a 1, 2008
One-or T o- amily Dwelling
S cfio F'ot3)ffcial'�se Only .
Building Permit Number: Date plied: d
Signature: !I U
Building Commissioner/I pector ofBui .Date /*
SECTI N . SITE INFORMATION,
1.1 Property Address•, 1.2 Assessors Map&Parcel Numbers
L la Is this an accepted street?yes no Map Number Parcel Number
r 1.3 Zoning Information: 1.4 Property Dimensions:
t 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2. Plk 4TY90VPNERSHIPt-`
2.1 Own of Reco
Ne rint) /am Address for Service:
Signature Telephone
SECTION 3:DESCRIPT,ION'OF PRO,POSED'WORK�(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4:ESTIMATED`CONSTRUCTION COSTS
Item Estimated Costs: Ofticial On.Use l
Labor and Materials) Y
1.Building $ 1 Building Pennit'Fee: $.Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Ttswn Application:Fee
TotalTroject Cost'(Item')x multiplier x
3.Plumbing $ 2. Other Fees: $ '
4.Mechanical (HVAC) $ List:y
5.Mechanical (Fire
Suppression) $ Total All]Fie $'
Check No.' Check Amount: Cash Amount:
6.Total Project Cost: $ L- ,0 ❑Paid in Full, ❑ Outstanding Balance Due:
�1
SECTIONS; CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Me L License Number Expiration Date
Name of CSL-Holder V List CSL Type(see below) y
T _ -Description,
Address � '� '� l U Unrestricted u Cu.
R Restricted 1&2 Family
Dwelling
Signqature '-- M Mason Only
l"2 7!/:5 t5 (3 RC Residential Roofing Covering
Telephone WS- Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Re istere H to I tprovement Contra for HIC)
� /D 5"_ -
HIC Cocppan Name
nt a �l iLrw Registration Number
Address q 7 L_LD
L � 7J-i7.�,{(�'�� Expiation Date
Signature / Telephone
SECTION 6c WORKERS'COMPENSATIONINSURANCE 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'g,AGENT OR"-CONTRACTOR APPLIES�FOR-BUILDING PERMITT ?
I O & U/Z 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.
Si nature of Owner - Date
SEGTION.76r OWN//EW, - AUTHORIZED;AGENT DECLARATION ,
sI, M as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
L l
Print Name /)fin // '
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of a 'u
"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(MC)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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
I'