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BP-870001.1 Property Addre s: / kaeazdi,/ 1.2 Assessors Map & Lot Number: Contact Person: -tom" — MaP �_ Lot ��- -- _ Phone Number:sz:--�(G I 7 1 0j 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal ❑ Private Well ❑ On Site Disposal System 1.3 Historical District ❑ Yes ❑ No Year Built ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ N ID o ate. Revised 5 /13 CONSTRUCTION PLANS ❑ SITE PLAN ❑ 2.1 Owner jR�1ecord: /� Jo�tvl /'raslrohaf i.4A L ( r 1' 1" �r7p, Name (pant) Contact Address ( Phone Number 2.2 Authorized Agent: _7�� 4�rt�- Name (pant) Contact Address Phone Number 3.1 Licensed Construction Superviso S lkdalty-license:-- License -Number: 2% - Company Name/Contractor Name: 7, # j % b 7CT Address:6 l'>ie S } �/1 T. .� Expiration Date: Signature: Telephone: 3.2 H owner Exemption - One & 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 affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: 6'Ves ❑ No Deck b Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition kRoofing idirr ❑ Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows_ Doors ❑ GEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): umpster on site ❑ Dumpster On Street Facility Name: 0— Location: A1&/ t'U � l�Afi b���✓J� *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 l7 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): inet! unif}V prfrnary €reeltriral gas;�a�arte; 'elecfricitp, otfier (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water. Gas Electric Fuel oil Other Item Es ' ated Cost ($) to be completed by permit applicant 1. Buildings , 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total =0+2+3+4) G SI3KlA' ©I1=Fly T (1Zj N �fso a ao�et�d;u►7ten tt�a�rt�r�s �ge[�' G'onr��;�ppFi��'I�or'i�uilclrperr�tjr - (Please Print) ,1 I, ,i0h� i"►QS�ro ►x� f14� g/�i as Owner of the subject properly hereby authorize�Lt/ to act on my behalf, in all matters relative to work authorized by this building permit application. a7- 13IJ -7 signaLr6 of Owner Date ECTIC?K r<6 UllfltrlEf/AlT1Q>RI�CiG)�(TI3ECI-F;ATIthl77 1, 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 and penalties of perjury. Si t Owner/Authorize Agent Date GT0 _1 t falTti Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $�'` Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft, y � Permit Issued to: a4meL&� tee 04, i