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BP-63179E 9 EN71PA ❑ Approval in Part (Per 780 CMR.5111.'13) 1.1 Property Address: Lot Area (sf.) Frontage Required Provided Front Yard Side Yard Rear Yard 7WaAer Supply (MGL c40 s54): 1.5 Sewage Disposal System: cipal ❑ Private Well ❑ Municipal ❑ On Site Disposal Sy: 'CONSTRUCTION PLANS 1.2 Assessors Map & Lot Number: Map 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: SITE PLAN Page 1 Page 4 C C C` I C E N C E (S Sct•TtON ORtCcR S'COfdIPENSATIC3N f S�IGE AFFIDAVIT f�GL c;;i52 S 2S) ,PF<OPERTYC1tt "3ER�'{1PtA[�T(iOR)ZED�', GPM <_.. Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this 2.1 Owner Record: % affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No Name (print) Contact Address Phone Number _... S�CT[ON 6=1?ESCRIPTIOItiI, OF PR©POSED;IORK {Check aif applicable) .: 2.2 Authorized Agent: G r _.5z , 44 !��'��P_�'Se, Y6' 0��4� r�'� ❑ Deck ❑ Pool Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove Name (print) Contact Address Phone Number ❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other I ...,.. �..,, SEG1lO;[U 3 COf�STRUGTION;;SERU(C,ES(Energy report required) (Shed/Garage) (Specify below) �.�_... h 3.1 Licensed Construction Supervisor/Specialty License : License Number: ® / ❑ Addition ❑ Replacement window/door ❑ Demolition Company Name/Contractor Name: (Energy report required) No. of windows Doors (Specify below) Greenwich Insulation, Inc. • Address: Expiration Date: / �j /� 'If new construction, please complete the following: Signature: ore-- I�j, 17 VC/ / / S/ J/ 3.2 Registered Home Improvement Contractor. Not Applicable ❑ ,g Single Family: No. of Bedrooms No. of Baths Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 No of Bedrooms Unit 2 No. of Baths Unit 2 Are you claming exemption from the requirements? ❑ Yes ❑ No ❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify). If Yes, Go to Section 3.3 ❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other Company Name/Contractor Name: Greenwich Insulation Registration Number (if none, state "none"): ❑ Air conditioning - (separate unit) Address: 75 Sharpe St. / 9 Y � ❑ None of the above to be provided , t(d • RI 02817 ❑ Hot Water: Gas —tl--- Electric Fuel Oil Other Signature:5Q Telephone: GIB Expiration Date: / 3.3 For Residential Remodel Work Only DesCf1 tiOrl Of proposed work: 3 k �2T / c°� 7T/e 14I✓ /,t 'f a .✓e} t,.. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:i,ce� QUESTIONS OR COMPLAINTS call or write: `�� ° n� r't' .SECTit3P & - ESTtIiATEii CQtSTRUCTiON Home Improvement Contractors Registration, One Ashburton Place -Room 9301, Boston, MA 02908, 617-727-8598 t' .Item.,. Estimated C st ($) to be completed 1. Building by permit applicant - _ _ ❑ I am a omeowner performin all the ork myself.. 2. Electrical AK)i3. Plumbing Owners Name (pri 4. Mechanical (HVAC) 5 Total (1 + 2 + 3 + 4) Signature: A WU11�.a s5EC7 fON 7A Otf�SER"AIJT%EOF217AT OAf P y si ing t e bove, 4 home ackno ledges that there will be no eligibility to the Guaranty Fund -i .. •;; ., �� g tY ;., Date: I, %. , as Owner of the subject property hereby authorize -/�QT� a c� 7 �`PdS� 3.4 Homeowner Exemption - One & Two Family Only to act on my beh%alf, in all matters relative to�work authorized by this building permit application. J/ / j� FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT ✓/ ` �� +���` h 5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individus Signature of Owner Date shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building. or structures, unless he or she is licensed in accordance with the rules and regulations promulgated b the BBRS entitled Rules e 9 P g Y R and Regulations for Licensing Constructioi ' „SEGT{Ott 7B,_,Q[fVidEt?Ir�i#Ti ORIZcb�AGEi!T ©ECLARATiQitl ' Supervisors. , M 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 Homeowne engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor I , �� �C/ , P �. ��5� , as Owner/Authorized Agent he declare that the statements and information 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 whin on the foregoing application are true and accurate, to the best of my knowledge and belief. 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 tha one home in a two-year period shall not be considered a Homeowner Signed Under the palrlS and penalties Of perjury. - If you are applying under this section sign below:'% Signature: gn Siature of Owner/Authorized Agent Date Your signature carries certain responsibilities, including but not necessarily limited to, general liability Page 2 Page 3