BP-85902RESIDENTIAL ❑ Phased Ap
proval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON-TRAN,'WFFRARi.V
1.1 `4o erty Address
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1.2 Assessors Map & Lot Number:
on act Per
Person:
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Map —/L Lot _�-
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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:
CONSTRUCTION
RESIDENTIAL.
SECTION 2=_PR0PERTY0
LRSHIP/AUTHORIZEQ AGENT
Owner Record:
Name (print)
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Contact Add res Phone Number
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2 Authorized A ent:
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Zo?tactAddress
Name (print)
Phone Number
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SECTION 3 �cb STRUGTION
SIERViCES _
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name:, / e-U
Address:
Expiration Date:
Signature: Telephone:
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 ff 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:
/gnature:
- rSEGTION "� u:W�RlCER'S _COIIePENSATION IIVSll12AI�IGE AFFIDAVIT-(MGL �;'f 52 § z5� . ` --
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
$CTIVN 5 = DESC12tPTION' OF, PROPOSED_)IStORK (Check allppitcatfe} r --
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition i Roofin idin ❑ 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 ❑ Dumpster On Street
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 urit)
❑ None of the above— f-hk*—
❑ Hot Water: Ga _ Electric Fuel Oil Other
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DINING ROOM FRIDGE'
PROP. FIRST FLOOR PLAN
12' EXIST. PASS -THROUGH 1x17 �(
OPENING TO BE by X X KITCHEN �O `�
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2' T-1" 2' 5'-5" Z
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CONFIRM WINDOW LOCATION
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4'-Lu
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BATH
BEDROOM X w/
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BEDROOM 2' W Q
BATH 30'
10'
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(2) 1.75" x 11.25" VERSA -LAM t n
2400 DFLVLs ( FLUSH FRAMED) I S \,►Tl� �� F'
2'6
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28' I 24'-10" `" S \Q�� V ENTRY (p
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