BP-71189RESIDENTIAL ❑ Phased Approval (R106.3.3)
1.1 Property Address: e E Szm %� �e �l` C, 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map % 5 Lot �a -
Required Provided
Front Yard 1.3 Historical District ❑ Yes XNo
Side Yard Year Built
Rear Yard
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
Municipal ❑ Private Well 0 Municipal VOn Site Disposal System ❑ Yes ❑ No Dater
Keviseu iun
El CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
2.1 Owner Record:
Contact Address
Na e (print) a0a H�
2.2 Authorized Agent:
Name (print)
3.1 Licensed Construction
Company Name/Contractor Name:
Address: AOa ILI1 d1 Q
Contact Address
pecialty License:
V, o
,&/,",/V— Telephone: Ng-DOy 7G3 ?13
w. 0.2
i
✓� �/!i Phone Number
x,4)9- go W 3 g
License Number: G O IM
Expiration Date:
y _ay-iy
32 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 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 Homeownershall 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
cf struct acc sory to such use and/or farm structures. A person who constructs more than
there is, or is intended to 6e, a one or two family dwelling, attached or deta
one home in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below.
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
❑ New Construction*
(Energy report required)
❑ Addition
(Energy report required)
❑ Repairs ❑ Alteration
❑ Accessory Bldg.
(Shed/Garage)
V"Replacennent window/door
No. of windows Doors _
*If new construction, please complete the following:
❑ Chimney/Fireplace
❑ Roofing/Siding
Single Family: No. of Bedrooms No. of Baths
Two Family:' No of Bedrooms Unit 1 No. of Ba s it 1 X
No of Bedrooms Unit 2 No. of B t Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, eledtricity, othe (s ecify}: !
❑ 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
❑ Woodstove/Pellet Stove
❑ Other
(Specify below)
❑ Demolition
(Specify below)
Signature of Owrier
(ten Estimate Cost ($) to be completed by permit applicant
4
1. Building
l
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = 0 + 2 + 3 + 4)
(Plea Pant r
I, /Cy V GL7j(a/(,%'__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.
Date
_ .. ,SECTION 713 = D -
�Ce? 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.
Signe4 under the pains and penalties of perjury.
�of Owner/Authorized
uthoriz�nt
Total Permit Fee: $ S
Gross Area - New Construction total sq. ft.
Gross Area - Alteration vital sq. ft.
Permit Issued to:
Less Application Fee: $25.00
Other $ Amount $
Debris Rarn04" Ay
1,!
per 9VIG �. d
2-/�"!
Date
Remaining Balance: $
k