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BP-66044RESIDENTIAL ❑ Phased Approval (R106.3.3) 1i�*roperty Address: i 0 e'/1.T f4cl Lz Assessors 1V1dV a L-ut IMUMUci. Lot Area (sf.) 0_0 Frontage Map Lot 7 - Required Provided Front Yard 1.3 Historical District ❑ Yes, ❑ No Side Yard Year Built Rear Yard ❑ Altering more than 25% per side of building 1.4 Water Supplyy MGL o40 s54): Sewage Disn°sal System: Has application been submitted to the Historic Commission? ❑ Municipal ; Private Well ❑ Municipal 0 On Site Disposal System ❑ Yes ❑ No Date: Rovkpri 10/11 ❑ CONSTRUCTION PLANS ❑ SITE PLAN 0 ENERGY REPORT RESIDENTIAL x ttfJl�l 2 ; PRQPI l!tili.SIFF tlQ�Q...., +t+1 T ,� �� r. 2. Owner Record: petir+rrw� �, Is ® v ! Name (print) Contact Addr4ss Phone Number 2 Authorized Agent: Name (print) Contact Address Phone Number �� , �� \�.:: �` �"",`� .� �I✓��I©l�'`. a �+ �' I��I�tJV��QIN.�i�%R � � � � �� °' ..�g�. ��. �M S.1 Licensed Construction Supervisor/Specialty License: - License Number: C 5 'Y3 7 3 Company Name/Contractor Name: 0 _ . 6 G 3 L Expiration Date: Address /S r S'� `/ V Telephone: - 3 � Signature 2 / p 3.2 Homeowner Exemption - Oned Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor. For the purposes of this section only, a"Homeowner' is defined as follows: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a Homeowner. If you are applying under this section sign below: Signature: Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this e affidavit will result in the denialofthe issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No h e .. x' i�Ft1PIpN. )IFIQI?}I C#Yit "CiC call;,ap Ii>rataale ,Tta,' ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction" ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other (Energy report required) (Shed/Garage) (Specify below) ❑ Addition ❑ Replacement window/door Demolition (Energy report required) No. of windows Doors (Specify below) "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 ❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other -(specify). ❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided 0 Hot Water: Gas Electric Fuel Oil Other Item 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total = (1 + 2 + 3 + 4) er1 7 ; riven d, Gdfi�l�� Estimated Cost ($) to be (cant as Owner/Authori d A ereby. declare,that the statements and information ;4 on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the ains nd.penalties of perjury. 2% 7- Signafure of Owner/Authorize Agen Less Application Fe _ 5. 0 f Remaining Balance: Total Permit Fee: $ Other $ Amount $ Gross Area New Construction total sq. ft. Gross Area - Alteration total sq. ft. j} Permit Issued to: I