Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
BP-77574
RESIDENTIAL ❑ Phased Approval (R106.3.3) $25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON-T BANSIaERARi .r SECTtQN_ $t f 1Nt3RIlAa7FO1J 5 s 1.1 Property Address: 16 6 % ��'!% 1.2 Assessors Map & Lot Number: Contact Person: Map_ Lot Phone Number: 1.3 Historical District ❑ Yes ❑ No 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ 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 5 /13 ® CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT RESIDENTIAL _ EGTlON2 PRf)PEATY(fWNERSHtP1AUiH00I4EDAGEhfT 2.1 Owne Record: CR; Name (print) Contact Address Phone Nufitber u 2.2 Authorized Agent:. / c -mot) d7c,� w 1 Name (print) Contact Address D� '' Phone Number �] �✓ u/ �a � C, 7 3 _ 3.1 Licensed Construction Supervisor/Specialty License: License Number: 6 2,32 Z Company Name/Contractor Name: Address: C OLpi w Expiration Date: Signature: ` Telephone: d 3 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, 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: '- �- _ •:;- . �SEGTIQN �� ltft©}?K£R`��QME?�NS�t1�2tNSt�RA1�l�EAFPL[�,��IIT {INGG� ��§-'�5} .._.. F= 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 x , 'y ;OTIalSt 5 .(BESs.RtPTtOI �F PRCt?[i�EDeORK �Gbeclillppttcalle} = s V ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. _❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors ❑,DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ 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 ❑ 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 0 Hot Water: Gas Electric Fuel Oil Other _ECTtO['1, .€Sl`IMAT€DIs�TRI_JCTIii�t _OSI' _ _ - Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) ' 5. Total=(1+2+3+4) - _ SECTtpN rA OWNER At3T�[ORI2�iTIlOTV = � - - „ (tv bearmpleteduFien owners agent;or conractar aptSGeor burldt_tt_g fsermttj (Please Print) � I�GZ:c.� V/�✓ r! as Owner of the subject property hereby authorize �—•-v" to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of 6wner Date _ - SECTION 7B=QWNERIAUTIORtZts® AGENT, DEGLARATION , I,+ " 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 pains and penalties of perjury. Signature of Owner/Authorized Agent Date _ - SECT�QN $ = _OFF�GE/t�fSpTOR`SNOTES _` Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft., Permit Issued to: 1