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BP-8076613e 6 WiIC u ca,66 Wzew /eddy Conservation Commission: Signature: D.P.W.: Signature: Fire Chief: Signature: Other: Signature: Brief description of work being perforr, Date: Date: Date: Date: ,.SECTiUN 1 -' SITE= INFQRMA'f�ON 1.1 Property Address: ��-{ �(tS�,, ,,,,,` �o �,`.Ir- 1.2 Assessors Map & Lot Number: Contact Person: Map 17 Lot - Phone Number: _ ?c�� oc� �-ZZL) 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal 9-15-rivate Well 19" n Site Disposal System 1.3 Historical District ❑ Yes ❑ No Year Built ❑ Altering m e than 25% per side of building Has applicati been submitted to the Historic Commission? es ❑ No Date: Revised 5 /13 C� CONSTRUCTION PLANS ❑ SITE PLAN ❑ENERGY REPORT SECT110-6 - ESTPMATED GONSTRUCTIQN CAST RESIDENTIAL SECT10N PRfPERTY:_aWNERSHiPIAUTH+DRiZED AGENT 2.1 Owner Record: �f2a LA� G G 51yi<' Z44 10 Name (print) Contact Address C> l' Phone Number 2.2 Authorized Agent: bc±R__e y-� 3�S�-{ 1�tk�.� s�l� (tea -�(,4. ,tom arc �o�s 3zz3 Name (print) Contact Address 0 Z G( 5' Z Phone Number SECTION = C4fSTRUGTIbN SIViGES - 3.1 Licensed Construction Supervisor/Specialty License: L&Are5 GSL License Number: Company Name/Contractor Name: �`,�� C Address: 3 a fro VM b--)o A-,_4AL,.> n AA OL.Lt3-7_ Expiration Date: Signature: Telephone: W 1 &04Z 3 Z-z "5 3.2 Homeowner 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: :,: _SECTION 4 WORKER`S C©MPENSATIUN _iNSURANGE AFi=1DAVIT (MGL 25) ." 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: B es ❑ No SEGTIBN - DESCRIPTION 3}F PROPOSED::WORK (Check al( applicable} - dDeck 151"p,001 ❑ Repairs ❑ Alteration 131C himney/Fireplace ❑ Wood stove/Pellet Stove 12New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors rl DEMOLITION (specify): djX t s� -St n!�Llf_ 4 i 1z Location of debris removal (per MGL C.40 Sec 54): 26umpster on site ❑ Dumpster On Street Facility Name: L- Location: GA i k *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 Ed Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify): & i (, to �r (fit wAC_:T � ❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): R(HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): vt _L-e A --a .,L t ..&A— PtW ❑ Air conditioning - (separate unit) ❑ None of the above to be provided U-Hot Water: Gas Electric Fuel Oil Other S