BP-67921RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON -TRANSFERABLE
—" Revised 10111
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❑ CONSTRUCTION PLANS SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
- r ;SECTION 2 _- PROPERTY QWNERSHIPIAUTHORIZED AGENT
.1 Owner Recordg
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Name (print) _ P�n;tac
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t Address i Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address` Phone Number
3.1 Licensed Construction Supervisor/Specialty License:
License Number
Company Name/Contractor Name.
Address:
Expiration Date:,
Signature: - '
Telephone:
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, an 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.
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If you are applying under this section sign below.
Si <ature."
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
❑ New Construction"
(Energy report required)
❑ Addition
(Energy report required)
❑ Repairs ❑ Alteration
❑ Accessory Bldg.
(Shed/Garage)
❑ Replacement window/door
No. of windows Doors
'If new construction, please complete the following:
Single Family: No. of Bedrooms
No. of Baths
❑ Chimney/Fireplace oodstove/P let Stove
❑ Roofing/Siding ❑ Other
(Specify below)
❑ Demolition
(Specify below)
Two Family: No of Bedrooms Unit 1
No of Bedrooms Unit 2 No. of No. of Baths Unit 1
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other Bspec• y):aths 2
❑ 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
I. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC
5Total =(1+2+3+
Estimated Cost ($) to be
(Please Print}
4a \,n�rac> or appttes fior building
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.
Signature of Owner
Date
pplicant
as Owner/Authorized Agent hereby declare that the statements and info
on he foregoing application are true and accurate, to the best of my knowledge and belief, rmation
ned un;der th ns and penaltieess of perjury.
of Owner%Adt'horized Agent
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 $
Date
Remaining Balance.- $ —19 --