Loading...
BP-94369RESIDENTIAL S'_cCTf62ffPEF�ilf _©11IFLSd [IPIU-7ttORfZED G'E}V.T 777777 2.1 Owner Record 3`1' 8arY7eyS 5-a �rs o t"tY T UG R• r1A 0L"7V 7r7-60R k Name (print) Contact Address Phone Number ,.tom le r2es-rVb ('f- V t �.2 Authorized Agent: /1 ilL/1 Ilrfi€S Ai< AJ;I if itA '2_9—'7900 Name (print) ContactAddress Phone Number 3.1 Licensed Construction Supervisor/Special-b License: jar /1 License Number: Q p �— Company Name/Contractor Name: r~� ,� t rind u1 S 1 - 16 17 -Z 5 �' + _ — g_ Address:0 Q PSer l � Expiration Date. 1 ,� Signature: Telephone: 3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WKO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: any Homeaymer performing work forwi rch a puiltling Permit is required shall be exempt from the provisions of this section; provides that if Homeowner engages a persons} for hire to do such work, that such Homeowrer shall act as supervisor. l orthepufposes a# 4 wsectiorr only a-"l orneowrter-is: efined-assfollows: Person(5)who Awns a parcel of land'=on which>he[she resides or it tends to reside, on which there is, or is infended :to be, a orre oriwo family dweliing, attached or detached structures.accessory to such°use arrdiar farrrt stiuctures..A person who donstructs more than home = e o e .one h in -a-two-year ar en d � iralLnotce c " onsrder -d H Y � a omeown r. e If you are:applying under this section sign below: Signature: .._...- ___...-_.__.....__-. _�ECTIOPi S ESTi�,�TE€;r �O@�i���tGTt€tiN:'_�z3BT SEGTtai �i a{l*1INE ACtTr{a�(�Tl�r� _ =:4 to be caFrt (eif+sd when -owners agent tsr ccnfrac€or app[res far bfaitding perririt 4 �_ - (Please Print), i, as Owner of the subject property hereby authorize f WA /VlsMA i o s in permit application. to act on m behalf; in all matters relative to work authorized by the building pe m t Y � f See r ar✓�l � A a c+ Signature of Owner Date $ECTtOi I Jf3 4tt�KERIAU EiE3 f�EQ AGENT iE LA ;T1`�7f I, `,r;arl n i 5 nn as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my Knowledge and belief. Signed under the pains d penalties of perjury. Signature of Ow o iz Date C G`TFClAk R- ctI�FEPFIIR� PFf'Tkr F L Total: Permit Fee: $ Less Application Fee: $25.00 Other $ Amount $ Remaining Balance: $ e Gross area - New Construction total sq. ft. worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this Gross Area Alteration total sq. ft. affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes ❑ No G Permit Issued to: ;11A't�� 0 © Deck = 0 Pool Repairs ci Alteratian Chimney/Fireplace ' CI iNaadstoveiPeliet Stave cC 0=New C0 Accoss6ri S[dg. 0_ Additiol 0 Roofing/Siding LrFrReplacernent windowfdaor (Energy report required} (Shed/Garage) (Energy report: required) No. of windows Doors 3 0 DE(VVDLITION, (specify): ,Location of debris removal (per MGL C.40 Sec 54): O Dumpster on site 0 Dumpster On Street Facility Name: Location:_ `if new construction, please complete the following: Single Family: No. of Bedrooms No. of Baths Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 No of Bedrooms Unit 2 No. of Baths Unit 2 0 Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify)( Boiler (heating) fuel gas (natural orpropane), fuel oil, electricity„ other (specify); 13 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): 0 Air conditioning - (separate writ) 0 None of the aboa— §1_-,d ❑ Hot'Alater: va3+___Electric Fuel Oil Other /i) s''O// (2) "aa'{> 0 f, p _91-4UC 4ci // gz I/