BP-81170RESIDENTIAL ❑ Phased Approval (R106.3.3)
1.1 Property Address: j stn &kA I { P. , 1.2 Assessors Map &Lot Number.
Contact Person: �/lC /Shckv Map L7110 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 ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
2.1 Owner Record:
&1�f p
Name (print) ,
2.2 Authorized Agent; 6!lam
Name
SEGTI00N 6 ESTIMATEDOIdS7RUC71t�NYCO
R$NIPIAUTHomzi5b AGENT Item Estimated Cost ($) to be
1. Building �..
2. Electrical
777/- / 1-777-0 3. Plumbing
Contact Adddr�re�s� Phone Number 4. Mechanical (HVAC)
S 6Ftt *&k � # d }/.7y8� 5 Total = (1 + 2 + 3 + 4) 7 ID
02-6 e* ` 4w I NWKII'_ 7N _ .. - SEt'Tfi!]Al 7 'nVItWFR.. trurAt�t7 Tirst�r
Contact
Phone Number
3.1 Licensed Construction Supervisor/Specialty License / 41c/t!�/( 1SLf1ti License Number: OQJ,x
Company Name/Contractor Name: U A) —t-1- . C
Address:7b JV 412_H� Expiration Dale:
Signature: ` — pr
Telephone. dl'� ���
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:
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
t)ESCRtPTION , —, PROPt3SEQ,-I ORK' heck alt i7plicabl
s��
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding 15 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
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
❑ Hot Water: Gas Electric Fuel Oil
❑ Dumpster On Street
Other.
(Please Print)
1, 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.
See -
Signature of Owner Date
I --LIARS LSf7LtJ , 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.
Sign under the
� pains an�enalties of perjury.
Signature
Total Permit Fee: $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
I
Less Application Fee: $25.00
Other $ Amount $
l d✓ �'x}L� f lt2�p OP?/It slt-�- . A�/D ��cx��
Date
Remaining Balance: $