BP-86522RESIDENTIAL ❑ Phased Approval (R106.3.3)
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1.1 Property Address: ?1/2— S 11 WA N4061<' M 1.2 Assessors Map & Lot Number:
Contact Person: B(-4n14 c s a r Map Lot _-_--
Phone Number: ,qC I- 7 Z 9- —cl Z) O
1.3 Historical District ❑Yes ❑ No
Year Built
1.4 Water Supply (MGL c4o s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal ❑Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5113
❑.CONSTRUCTION PLANS 0 SITE PLAN 0 ENERGY REPORT
ftEr.InFRIVIAN
1416"IULn I InL
SECTION 2 -.PROPERTY-OWNERSHIPIAUTHCIRIZED
AGENT.—
-114 2- '5 M i4-), M ec K sos'
2.1 Owner Record:
5A/i 4 n;�� 47
S- MA 0,1714 SO 0
Name (print)
contact Address Phone Number
2.2 Authorized Agent:
Z_Sdi,
/I /,I Y Z 2&- q?00
CIJL;1-101,G/S
J'.r�(D 0,2gA
Name (print)
Contact Addfess Phone Number
SERVICES T U N ICES
3.1 Licensed Construction Supervisor/Specialty License license Number: Z-6-ZC7
Company Name/Contractor Name: IoAe.,-I-) A[-,J F-lklaI4
Address: 1-6 k1_4-Jh 2,f 6,�' _ Expiration Date:
ar 1
'�KQ
Signature' —2 , Telephone: -Alot -.29-
3.2 Homeowner Exemption - One & Two Family Only Section I I G.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:
6O"SWSt MIVCB a►FP1DA�/M
Workers 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: des 0 No
Sqmoiw
fog 5,�_]DESOMPTIOWO"1100 _(C600fi*��bt6j
13 Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 11 Woodstove/Pellet Stove
• New Construction' 0 Accessory Bldg. 0 Addition 0 Roofing/Siding O/Replacement window/door
No. of windows 4 Doors
(Energy report required) (Shed/Garage) (Energy report required)
• DEMOLITION (specify):
Location of debris removal (per IVIGL C.40 See 54): 0 Dumpster on site 0 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
13 Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
13 Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
IJ HVAG (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
0 Air conditioning - (separate unit)
11 None of the above to be provided
13 Hot Water: Gas Electric Fuel Oil Other
SECTION-6 - ESTIMATED CONSTRUCTION: CAST
Item .-Estimated Cost to be completed by permit applicant
1 Building
2. Electrical
-3. Plumbing
4. Mechanical (HVAC)
5. Total =(1 +2+3+4)
9ECTLON- 7A -w.= ER AUTHORIZATI0 N
i_fde b'u
Ito rrict&
(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.
— � -Aj4n_-4 Crvifaac_+ — Date
Signature of Owner
SECTION7B oWNOWAvuort2tb AGENT DECLAKATION
BCD 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 pain and penalties of perjury.
Gross Area - New Construction total sq. ft,
Gross Area - Alterz
Permit Issued to:
Less Application Fee: $25.00
Other $ Amount $ —
Date
Remaining Balance: $