BP-6701711.1 Property Address: 1-13-3 Sj m f% IV,.c e rPx cf
Lot Area (sf.)
Required
Front Yard
Side Yard
Rear Yard
Frontage
Provided
(1.4 Water Supply (MGL c40 s54): 11.5 Sewage Disposal System:
I9 Municipal ❑ Private Well ❑ Municipal A On Site Disposal Syste
1.2 Assessors Map Lot Number:
Map (�/7 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:
1 n/11
`" - 0 CONSTRUCTION PLANS ❑SITE PLAN ❑ENERGY REPORT
RESIDENTIAL
SECTION 2 = PROPERTY OWNERSHIPIAUTHORIZED AGENT°
2.1 Owner Record:
i GfiYrLI Gtl i^Y' JContact
Aa T 6y6
Name (punt)tAddress. Phone Number
2.2 Authorized Agent:
Name (print) Address
Phone Number
SEGTIdN 3 CONSTRUCTION SERVICES..
3.1 Licensed Construction Supervisor/Specialty License: License Number:
Company Name/Contractor Name:
Address: Expiration Date:
Signature: Telephone:
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 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:
ti 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 provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
SECTION 5'� DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ,Accessory Bldg. Roofing/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
1. BuiItem Estimated Cost ($) to be completed t
lding
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4) 2 t'0o
- - SECTION 7A -OWNER AUTHORIZATION
(to''be completed when owners"agent;,or coritradtor applies for building p;
{Please Print)
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.
Signature of Owner Date
it
I, /3a 14Jkll<'--e t" , as Owner/Authorized Agent hereby declare that the statements and information
on the foreg Ing 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 /
i
S 00
Total Permit Fee: $ Less Application Fee
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration al sq. ft.
Permit Issued to:�
Remaining Balance: $
U /�
d
Debris RemOV�w
per MGL G.40 Sec. 54
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