BP-95845REST ENTI L ►l A..----._,
— --•�r���, �,� �• nds dppucanon Deen submitted to the Historic Commission?
❑ Yes ❑ No Date:
d 5 /13
CONSTRUCTION PLANS SITE PLAN ®ENERGY REPORT
SECTION;2 Pf{tPERTYEWNER$tIIP%AUIHORIiED.AGENT`-
2.1 Owner Record: i�tlygv�tr JLTNCrLlE t�
�IsA7.)44 uA �at�•-c �SS eC :
/ �, r�
���� t�
Name (print)
Contact Addresi' Phone Number
2.2
.�A-lam,utthorized /AgeentA:
- kf l �'J/ � _
�"
A Is 1�% VAA � x 7�� . GZ1 V-6
Name (print)
Contact Address Phone Number
_ = SECTION 3 4 CONSTfRPP
IONS RVICES
3.1 Licensed Construction Supervisor/Specialty License:
License Number -
Company Name/Contractor Name:—c-,UAA CAP-, a/ t -- 1�— le -4 t '7 G -7 0`�:
Address: t t ,J v "�tZ, S ,'Prat ce-7
Expiration Date:
Signature Telephone:Sao5 7 7/ O/
3.2 Exemption
Ho eowner - 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:
- _ _ _- r_SEC�iaTi � �IfTORKER`�C0�IAPEKS;4TIQN !INSURANCE AFPIDA,VIT- {MGlrc 152 §==25} � .. _s-._A r
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: �Ues ❑ No
-- - ,SECTION 5 `ESRrPTIt}Id OF_PRQPO:.SED WrR}S,{ttieskll �ppltcable�_ z
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows _ Doors
EMOLITION (specify): ✓AZ1��
��Ce
Location of debris removal (per MGL C.40 Sec 54): 011umpster on site ❑ 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
❑ 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
Estimated Cost ($) to be completed by permit applicant
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total +2+3+4)
C-. ` `
a scTron�A oN1=R AtiTHariz�16� = _
benpletecf agen# ter canffactvt`applr s fofuildirig
{fo when_ ov�rties permit}
19L-�
1(`subject hereby
property authcuze.r✓�-•� <
to act on behalf, in all ma s el tive to work thorized by this building permit application.
Signat e of Owner Date
SEGTION?DECLARATION ,
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.
7--
Signature.df ner/Aut ized Agent Date
-NA,.- ; OFFICE/INSPEC7+3R'SNOTJS
Total Permit Fee: $
Less Application Fee: $25.00
Remaining Balance: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. _
Permit Issued to: -2mleat/YLYf%�f ��� k
,��� -All
[ESGI3PT{OI3Fsf ORFiB1NG�ERFt�R_ EDz_ r
t.,.TGT13t . _ _ .
J