69 BUTLER ST - BPA-14-376 Z or_ 2-
The Commonwealth of Massachusetts CLfY OF
Board of Building Regulations and Standards SALENI
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: DateAppli ' I { - p!F�-- I
v� � 6—
Building Oliicial(Print Name): Signature - Date
SECTION 1:SITE INFORMATION
LI PrupertWxdress: 1.2 Assessors Nlap&Parcel Numbers
ST
I.1 a Is this an accepted street?yes✓✓o Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wader Supply:(M.G.L c.40,§5a) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP`
2 Ownert of Record:
,5me(Print) City, tale,ZIP
Z,,5 ROT14r-Ni
o.,md Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other IYSrpecify! a.-L am.)!—
Brief Description of Proposed Work': S`irl"n r,nd 0� LLB 4e
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S dJ 1. Building Permit Fee:S indicate how fee is determined:
Electrical ❑Standard City/'town Application Fee
2. ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
d. Mechanical (HVAC) S List:
5. :Mechanical (Fire S
Suppression) 'total A Fees:S
Cheek No. Check Amount: Cash Amount:_
6. Total Project Cost: 3� Oct W 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction SupervisorLicense(CSL) /OQ
G, r .+��{(.vT License umber Expiration Date
Name oFCSL Bolder
List CSL'fype(see below) io P _
o.and Street 'type Description
U Unrestricted(Buildings u to 35,000 cu. It.)
LYJrJ ./Yl/� OL4UY R Restricted ly@2 Family Dwelling
City/l'o n,State,ZIP M Nlasonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
T&I S-55a,L I Insulation
'1'ele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ` V07br
r
I.�tL 11.o T �rt_�aeskt,et �� HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
tt S" yt.ionu.s '
N and Street Email address
LyaN .01A, r?1S,6y 7e/575 �a► c
CityfTown, 5tate,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 .........`L7� No........... ❑
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_F54 r_rd
t9 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:OWNEW ORAUTHORIZED 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.
I&�,11.�., Ta o upAz j!-6'o� 3
Print Owners or Authorized Agent's Name(Electronic Signature) Dane
NOTES:'
I. 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 1MLG.L.c. I42A.Other important information on the HIC Program can be found at
Mww.mass.cov!oca Information on the Construction Supervisor License can be found at w%ow.masss,,ovAIps
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. It.) 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'