BP-45668SECTION 8 -INSPECTOR'S REVIEWICOMMENTS
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD :.
e
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: l fr�1.%Q��, v Date: aP`-' 2, o
E TION - APPLICANT NOTIFICATION '
Applicant informed of above: Date: Time. =�/ J Clerk -
Comments: vC,
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
$25.00 APPLICATION FEE IS NON RE -FUNDABLE. ♦C NON -TRANSFERABLE
DEPARTMENTAL APPROVAL `.:
Zoning Review:
Signature
Date: y !
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
Date:
Board of Health:
Signature:
Date:
Conservation Commission:
Signature:
Date:
Other:
Signature:
Date:
e
Brief description of work being perform
SEC ION 9 - SITE INFORMATION
1.1 Property Address: �i
' "f.Z Assessors Map & Lot Number:
Nearest Cross Street:., -.In � �'`t� r �"i-�1
Map -z!�' Lot
_el
zm
Subdivision Nam�-�J i
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1.3 Historical District ❑ Yes AJ-KS
Total Land Area Sq. Feet:
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.4 Water S ply (MGL cr40 s54):
❑ Private Well
1.5 Sewage Disposal System:
❑ Municipal jP0n
unicipal
Site Disposal System
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
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DCeinPKITIAf
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 O,ynerord:.
37
Na a (pri t)
Contact es Phone Number
O ,
•
`
2.2 Authorized Agent:
�%v• �j -g
_(�"�
N e rint)
CordadAddres Phone Number
SECTION 3 = CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
aTC3
Licensed Construction Supervisor:
License Number
<<
Address: . 40.
Expiration D/te:
Signatur Telephone.
3.2 Registered Home Impro ment Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? es ❑ No
_ If No, go to then ection!
Are you claming exemption from the requirements? ❑ Yes o
If Yes, submit the r quired affidavit!
Company Name:
Registration Number (if none, state "none"):
/�iLo
'� �• �•
Address:
�j
Signature: Telephone
xpiration Date
3.3 For Resi a t' l o el RemW rk Only
11-1
PERSONS RACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR CO INTS call or write:
Home Improvement ctors Registration, One Ashburton Place - Room 1301, B �02108, 617-727-8598
❑ 1 am a Homeowner performing all the wor elf.
Owners Name (print):
Signature:
% si ' the above, the homeowner acknowledges that there will be no eligibility Guaranty Fund
Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOW S WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR E OWN PROJECT
109.1.1 Licensing of Construction Supervisors: cept for those structures governed by Construction Control in ion 116.0, effective July 1, 1982, no individual
shall be engaged in directly supervising persons engaged in truction, reconstruction, alteration, repair, re al or demolition involving the structural elements of buildings
or structures, unless he or she is licensed in accordance with the rul regulations promulgated h6 BBRS entitled Rules and Regulations for Licensing Construction
Supervisors.
Exception: Any Homeowner performing work for which a Building Permit is required -shfflIqGZexempl 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 ervisor.
For the purposes of this section only, a "Homeowner is defined as folio Persons) who owns a parcel o on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attach detached structures accessory to such use an structures. A person who constructs more than
one home in a two-year period shall not be considered a Ho owner.
If you are applying under this s on sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of tbU GMK Kb.2.1b)
- SECTION 4 '= WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c152 § 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: es ❑ No
SECTION 5 = DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. WKoofing/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 co ction, please complete the following:
Single Family: No. of Bedr No. of Baths
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 0. of Baths Un'
❑ Furnace (hot air) -fuel gas (natural or propane), fuel oil, electricity, othe city):
❑ Boiler (heating) -fuel gas (natural or propane), fuel oil, electri ' er (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, e, electricity, other
❑ Air conditioning - (separate unit) D
❑ None of the above to be provid I T
❑ Hot Water, Gas Electric Fuel Oil Other
cription of proposed work: ke 56%lL e 6i n p-• ,
r SECTION 6 -`ESTIMATED CONSTRUCTION` COST
Item Estim ted Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total= N +2+3+4)
(P�le-a�s-e-Print)
I, ��A/'Tj"T T_, 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.
0p % Q�►
Sign a a of Owner Date(
SEECTION 76 - OWNER/AUTHORIZED AGENT DECLARATION.
I, "• v�� , 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.
*-- 72�b JRis/o�
Signature of Owner/Authoriz Agent Date