BP-63672iNSPEC O . S': RE . i— WrCOFIlrENTS.
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1.. Date plan reviewed: AUG 2 3 7o11 . ,
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: i�'�/��
Date:
4. HOLD subject to Zoning Board of Appeals action:
Date:
Comments:
Date:-.AUG 2 3 2011
Inspector's Signature:
SECTIOIr9 S ,APPLICANT i�IOTIFi'OATiON
Applicant informed of above: Date: Time:
Clerk:
Comments:
Total Permit Fee: $
Less Application Fee: $25.00
Remaining Balance: $
Other $ Amount $
TOTAL FEE:' Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
/
Permit Issued to: +
SECTIC [ I=;4[3DtTIONAL'CbIQIMENTS/SKETCHES"
Page 4
LJ CONSTRUCTION PLANS SI i L PLAN U ENERGY RLPORT
Page 1
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„ •. " S -c Tb 4--,'. bkk. ER'S COMPEI3SATiOI tNSURA�2GE,AFFIDAV[T.( GL c.�52: 2�) ;,
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
.'7,stCT10N5 `',DESCR?P"ilbNOF°<PROPOSEDINORK'tChec"llapplicable); �....,,', .:�`•". ' "
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction" ❑ Accessory Bldg. Roofing/Siding, ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows Doors (Specify below)
C
A6, AS
*If new construction, please complete the following:
P
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
F
❑ 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)
C
E.
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed work:
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E
(S)
......:sECTIOM'6=;ESTt�dsATEt;'GONSTRUCTION CosT,..W
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
O, o
-
2. Electrical
70
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
�� SECTION
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completed"whets
7A OwNER AUTHORIZATION \�
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owrter`s;agent or:<contracfar applies.far,-building Y ;
(Please Print)
I, M jz'He r (, b( �—ft�l(,=, as Owner of the subject property hereby authorize
to act on my behalf, in all matters relatic-authorized by this building permit application.
k �. g� ��rll. ► �(
Signature of Owner Date
"SECTION 7B:;, OWNER/AUTHQRIZED AGENT DECLARATIQiV ....... �. ,, . : .
I, �� `tJ G �� % 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..
Signe er th ai pen • s of pe ' ry.
IA 11
1177MU—re of Owner/Authoriz Agent Date
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2.1 Owner Record:
Name (print)
Contact Address Phone Number
2.2 Authori ent:
��� ��� 5.
Name (pnn
ContactAddress,w�,.+pq�� Phone Number
3--COf�STRUGTIOPI SERVICES,
3.1 Licensed Construction Supervisor/Specialty License :
License Number.
Company Name/Contractor Name: � G
Address:
Expiration Date:
3 moo.
Signature: Telephoner
3.2 Registered Home Improvement Contractor: ; ��
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? l�l Yes ❑ No
Are you claming exemption from the requirements? ❑Yes ❑ No
If Yes, Go to Section 3.3
Company Name/Contractor Name:. l � �j
RegistratioCn Number (if none, state "none"):
Address: '� W
Signature: Telephone: 6 Expiration Date:
�w
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, 617-727-8598
❑ I 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 Constructioi
Supervisors
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