BP-862163 a �Xft //%
4�
RESIDENTIAL ❑Phased Approval (R906,3.3) 41
$25.00 APPLICA11 N FEE IS NON BE -FUNDABLE & NON-TnC lTS1MB"LE �
1.1 Property Address: I S , >� �d t`'� 1.2 Assessors Map & Lot Number -
Contact Person: �Jf�- �l �� t MapLot
IPhone Number:
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
Private Well �eOn Site Disposal System
1.3 Historical District ❑ Yes )9 No
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
rl CONSTRUCTION PLANS'
_. SECTIl3N PRfiPERTYzfh1ERSHIP/�[iTHORIZED
2.1 Owner Record:57
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address
Phone Number
�$ - .-� ,-- -� _ .SECT10N3 GQTVSTfZUGTtONS�RVIGE� _ _ _-
Address:' FT.
3.1 Licensed Construction Supervisor/Specialty License: i Z f � �' � �' � �
License Number:
Company Name/Contractor Name: �� d r�.r�. It �� ��� � � S ��,
�� • ��"L Expiration Date:
Signature: Telephone:
3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS WH INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception: Any Homeowner performing work for which a ilding Permit is required shall be exempt from the provijoris 6f ihis section; provides that if a Homeowner
engages a person(s) for hire to do such work, that such Homeo r shall act as supervisor.
For the purposes of this section only, a "Homeowner" is defined a lows: Persons) who ow arcel 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 etac tructu ca c. ssory to such use and/or fans 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
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: ❑ Yes ❑ No
❑ Deck ❑ Pool ❑ Repairs )qiAlteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove .�
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energyreport required)
p q ) No. of windows Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster 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
❑ Hot Water. Gas Electric
Fuel Oil
Other
Item Estimated Cost ($) to be completed by permit applicani
�Electrical
bQ
d t7 d
3. Plumbing 66 b _
4. Mechanical (HVAC)
5.Total =(1+2+3+4)
(Please Print)
1, , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Sk C�Z�r�
Signature of Owner Date
SEGTIQN 7B _IAiNER/AUTHRIZEQ.1kGENT DECL,4RATIC7N
as Owner/Authorized Agent hereby declare that the statements and ' Information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the p nd penalties of perjury.
1
l
Signature of Owner/Authorized Agent Date
Total Permit Fee:S$
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
Less Application Fee: $25.00
Other $ Amount $___ Z 57�
r 1 t
e4, �c� �t y
i
Remaining Balance: $ 6
J e e �D 16 Lt -S W% rX