BP-70851RESIDENTIAL ❑ Phased Ap
proval (R106.3.3)
$25.00 APPLICATION FEE IS NON RE -FUNDABLE & NON -TRANSFERABLE
Contact Person: j4jPLWFV-) Jul
Revised 5 /13
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDERTIAL
2.1 Owner Record:
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Name (print)
2.2 A horized Agent:
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Name (print)
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Contact Address 6z7ye Phone Number
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Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License: License Number: 6 l z Z
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Company'Vame/Contractor Name: 8?jjl(' 011VA0k;6 RAJ)A,[,K �,PAIA
Address:
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Signature. Telephone: 'tfb(-7/��G 3Q/� 07 2-,o >ol S
3.2 Homeo r xem on - 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: XYes ❑ No
❑ Deck Q ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Repla
(Energy report required) (Shed/Garage) (Energy report required) No. of
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54):
Facility Name:
*If new construction, please complete the following:
Single Family: No. of Bedrooms
❑ Dumpster on site ❑ Dumpster On Street
Location:
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
_a
rl
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
TED CONSTRUCTION COST
Estimated Cost ($) to be completed by permit applicant
(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.
Signature of Owner
1, /A—RFU) S.
on the foregoing application
Signed under the pains
Signature of
Total Permit Fee: $ ! 5
Date
, as Owner/Authorized Agent hereby declare that the statements and information
and accurate, to the best of my knowledge and belief.
of perjury.
(Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
/Wt1719"< 5 _ .
Less Application Fee: $25.00
Other $ Amount $
Dat
Remaining Balance: $
J_Y