BP-69286SECTION 8 'INSPECTOR'S REVIEW/COMMENTS
RESIDENTIAL ❑ Approval in Part (Far 780 CMR.5111.13)
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- ,► �t SECTION 1 = SITE INFORMATION
9.1 Property Address: i 3 �M I� H N� 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map Lot
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard Has application been submitted to the Historic Commission?
Rear Yard ❑ Yes ❑ No Date:
1.4 Water Supply (MGL c40 s54):
❑ Municipal ❑ Private Well
0 CONSTRUCTION
1.5 Sewage Disposal System:
❑ Municipal ❑ On Site Disposal System
BEs0®ENTIAL
;SECTION 2 PROPERTYOWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
P�v 111y A43 �2N a,-E-1ia-Z CoTD '339 -q87 94 ,�z,
Name (print) Contact Address Phone Number
2.2 Authorized Agent: A ' � �+ ) � n ,�y —�/
030
Name (print) Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES .
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: 1QqR6E2Z p #�� License Number:
Address: �%ti( �1~) Expiration Date:
Signature: elep , ne: �r %i
V3.2 Registered Home Improvement Contractor: Not Applicable ❑
o Are you a Home Improvement Contractor subject to (780 CMRA 10.R6)? ❑ Yes ❑ No
�6. If No, go to the next section!
OAre you claming exemption from the requirements? ❑ Yes ❑ No
V If Yes, submit the required affidavit!
Company Name: t Ja/Z_ e)�I Registration Number (if none, state "none"):
Address: `77 .. 6L- � E2 ,,�U?„� ,f �� (,7 -
r / / �t1J
61
Signature lephone: ` 9f `j �� Expiration Date: /
3:3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
or structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licenising Construction
Supervisors.
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:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
SECTION 4 - ORKER'S COMPENSATION INSURANCE AFFIDAVIT; MGL c 152 § 25
Worker's Compensation Insurance Atdavit 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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water. Gas Electric Fuel Oil Other
Description of proposed work:
SECTION 6 - ESTIMATED CONSTRUCTION COST.
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
- SECTION'7A - OWNE AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit) -
(Please Print)
"
I, `%/ M ? / , as Owner of the subject property hereby authorize f-64d At lkalt /V.
to act on my b If, in all matters relative to work authorized by this building permit application.
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Signat re of Owner Date
-SECTION 713-`OWNERIAUTHORIZED AGENT DECLARATION
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.
Sinne nd r the pains and penaltie erjury.
S natu of Owner/Authorized Agent Date