BP-79226RESI®ENTI ` ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE-FUNBABLE & NON -TRANSFERABLE
❑ Fire: ❑ Gas ❑ Electric ❑ Other, ❑Water Card ❑ Sewer Card
Chief Cut off _ , but Off _> ' Cut Oft Cut
DEPARTMENTAL APPROVALS)
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of work being performed;
1.1 /Property Address:
010 tact Person: Ml� g (<
P one Number: 6--Cg — & q; - 01 y ci
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
1.2 Assessors Map & Lot Number:
Map M Lot
-
1.3 Historical District ❑ Yes ❑ No
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
i
Revised 5 /13
11 CONSTRUCTION PLANS ❑SITE PLAN ❑ENERGY REPORT
RESIDENTIAL
SECTION 2-RROPERTYOWNERSHIP%AUTHORIZED
AGENT,
2/1 Owner Record:
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
�9fL r/S
3l !c'�J SccJ�rti'i�
Name (print)
Contact Address _O �GAJ hone Number
SECTION 3 = CONSTRUCTION
SERVICES
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name: '', rfv5 e e-,;t- ii2ue 7-1o.,-J
Address: 5"R /Z-b � rfivi
Expiration Date:
Signature: Telephone: 604 O J C/(Z it
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:
"s. SECTION-`Y{IORKER`S;COMQEHSATION INSURANCE'AFFIQAVIT,(MGL:c 152
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
'SECTION 5 � DESCRIPTION QE PROPOSED WORK,(Check all applicable)
❑ Deck " ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fir. place ❑ 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
I Item I Estimated Cost ($) to be completed by permit applicant I
1. Building y
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0 +2+3+4)
SECTION 7A -OWNER AUTHORIZATION`
(to be compfeteii"when owner's agent or contractor applies fortiuitding permit
(Please Print)
I, CLA t/ 0 C GC- L t AM 5 as Owner of the subject property hereby authorize MA4R k- F r—A 21
to ''act n my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, C �- A U 19 E lT C ti ( fl/pr�; , 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 anp penalties of perjury.
Q
Signature of Own r/A t o gent Date
Total Permit Fee: $ 7 5"' Less Application Fee: $25.00 Remaining Balance: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total ,,sgq.�. ft.
Permit Issued to:
9 L?
14-0-1110t / / r
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