BP-64591RV Y, SECT€ON^8':- 3NSPECTOR'S R£�l*Y'J1^uflM[11EfdTS - �:•,--: !.F -
1. Date plan reviewed:
2. DENIED (see project review worksheet): OCT 2 Lei
Date:
3. HOLD
Reason:Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: Date:OCT 2 Q �R1
_ ,:- ;,-_, :" ;; "° ECTt 9=AP,i?LiCANT;NOPFICATION^ _
Applicant informed of above; Date:1 'l Time: Clerk:
a
Comments:
.,.,SEC710NkU:OFFtCEfINS?'ECTOQ`SdvO7E3
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Total Permit Fee: $ C S
Less Application Fee: $25.00
Other $ Amount $
Remaining Balance: $
TOTAL FEE: Gross Area - New Construction total sq. ft.
y^ Gross Area - Alteration total sq. ft.
Permit Issued to: �6 ��I114 ��
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Page
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1.1 Property Address: / ��p SLIR HPC //t 1 R/1.2 Assessors Me Lot Number
Lot Area (sf.) Frontage Map Lot
Required Provided
Front Yard 1.3 Historical District ❑ Yes - Qd No
Side Yard
Year Built
Rear Yard -
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54): i 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
❑ Municipal IR Private Well 0 Municipal 5kOn Site Disposal System ❑ Yes ❑ No Date:
CONSTRUCTION PLANS LJ SITE E PLAN ENERGY REPORT
Page 1
F,7-3Z 3 t
<SECTIOa21-PR0�=ERTYOWNERSHPJAUTPORIZED��Cci'it,-
2.1 Owner Record:
pit-40V-d
Name (print)
Contact Ades Phone Number
Fe 4 Z£r-
2.2 Authorized Agent:
pekf-y-r7 !;-W K f✓
D /
7-5-6 I o�at� j1�q 308 �3� as37
Nam
Contact Address Phone Number
wUp - �wm-F SECTSOWVt CONSTRUCT{ONS-RVICESi!
3.1 Licensed Construction Supervisor/Specialty License :.
License Number. 7 5-7
Company Name/Contractor Name: �^ W try
Address: 7 5-6 pa-tAvn' 6 ei
Expiration Date: -
Signature: A` "y/ Telephone:Sd'E0(vc,�37
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? FLYes ❑ No
Are you claming exemption from the requirements? ❑ Yes ❑ No
-- If Yes, Go to Section 3.3
Company Name/Contractor Name:
Registration Number (if none, state "none"):
Address:
Signature: Telephone:
Expiration Date:
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
.QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8596
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date: -
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building
or structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction,
Supervisors.
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 Homeowne
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor
Forthe 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 whit
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 this
one home in a two-year period shall not be considered a Honieowner
]'you are applying under this section sign below:
Signature:
Your signature tames certain responsibilities, including but not necessarily limited to, general liability
r7i
SECTION 4 - wOP, ER'S CONIPENSAT!ON INSURANCE AFFIDAVIT (MGL c 152 § 25)ri + w�
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: Q Yes ❑ No
5 -,,:DESCRIPTION OFr"PROPOSED'WORK (Ch6'ik all
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction` ❑ Accessory Bldg. MRoofing./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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description f proposed ork:
wdC ,(SECTION 61,='ESTIMATED
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1 +2+3 +4)
/
r,'SECTIONrA OxLrNERAUTHORIZATION`Ih'r'n 'I W 1,4 t ,{T ff.�
.. , c h,li 7 wt+fJ), :n li
.+.,,' i<•ner'!.
{tobe completed agenti6ont o
owders agenYror contractror apphes.:for buildinggermtf),
,L�vhen
lea ,(�rint)f., � (Zc�(a.n.CE ,� 6�U-(<.Z s, ftt Q c, y� / ,l
I, ✓ lrll 1KF� /�Q1UN%r asOwnerofthe subject property hereby authorize Sat-L wAI(4f-
to ac on my behalf, in all matters relative to work authorized by this building permit application.
(' f
�Gr
Signature of Owner Date
,, '#M%i'ISECTION 76 "O NER/AUTfiORIZEDAGENTDECLARATION(;1!
',+
I, r3.^,Vr i WA I K e v 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.
2,Jejl-t- - /oh /it
Signature of Owner/Authorized Agent Date
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