BP-66270RESIDENTIAL ❑ Phased Approval (R1D6.3.3)_
1.1 Property Address:,;( q V Aft-,,
Lot Area (sf.) Frontage
Required
Front Yard
Side Yard
Rear Yard
Z"
Provided
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal
r 1.2 Assessors Map & t Number. i
Map / Lot /-
1.3 Historical District ❑ Yes XNo
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
tern ❑ Yes ❑ No Date:
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION 2 _'PROPERTY OWNERSHIPIAUTHORtZED AGENT
2.1 Owner Record:
k�� s
Name (print. y. T Contact Address Phone Number
�^ --.
2 2 Authorized Agent:
Name (print) Contact dress Phone Number
SECTION 3 -CONSTRUCTION SERVICES '
01L
3.1 Licensed Construction Supervisor/Specialty License p,6,o `hp� 9 License Number. - % 1?
Company Name/Contractor Name:
Address: J I A ta / d- Expiration Date:
Signature: Telephone:oq a _ a -1 y Homeowner Exemption - One & Two Family Only Section 110.R5.1.8.1 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:
SECTION 4 - WORKER`S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. failure to rovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Yes ❑ No
4
"SECTION 5 ' DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. , oofin /Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows Doors (Specify below)
"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
Less Application Fee:$�o Remaining Balance:.
Total Permit Fee: $ ��
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration
nttotal
sq. ft. /
Permit Issued to: �1 9� (� lUC
`SECTION 8-ADDITIONAL COMMENTS/SKETCHES
r"Y
Loodon A
t�'�ris Removal
per M131- CAO Sec. 54 ,