BP-90438RESIDENTML ❑ PhasedApbrova! (R106.3.3)
$25.O0 APPLICATinN + ip.. LC MANT UIP- NTPW M A wbT
1.1 Property Address: Q J (3QKIm
Contact Person: ��dcR �Dt'an
Phone Number: S�or Q0-7 SS-aZ
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
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?
Cl Yes ❑ No Date:
Revised 5 /13
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DESIDENTI,
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2.1 Owner Record:
Sa�c�cQ (��ran
�S� irne S66 ao�sa�
Contact Address Phone Number
Name (print)
2.2 Authorized Agent:
Name (print) ) Contact Address Phone Number
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3.1 Licensed Construction Supervisor/Specialty License: License Number:W` � 1Q�'tf (�
``Address: (nl %
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Ex Irafiort Date:
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Signafi re.*g /b
3.2 Homeowner t xemptlon - 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 Binding 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 helshe 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:
""' 7 1'... � � --Rt r�,•_� 3O ��£�'f�'1s1� � 7F,���'""S� � y(`j���#,.• _.��.��'i}jI f •H�1yv.- .,sT-�+-�cP _"4•'-.ti`.Z.
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit will result in the denial off theissuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
+S � \S.tii%?i!'GV.if �Y 3. ~t w�"2 .fir _• in _.^'��r ila-'i
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/F'replace [IWoodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition
Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows_ Doors
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DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): 2 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 unit)
❑ None of the abow4 add
❑ Hot Water: Ar Electric Fuel Oil Other
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Item
Estimated
at d Cast to be
$ completed applicant
O b ermit
P Y P
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0+2+3+4) S 10 qq
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(Plea Print
I, ar4 C 01 �� (�� , as Owner of the subject property hereby authorize O�CA M
to act on my behalf, in all matters relative to work authorized by this building permit application.
Sigheture of Owner Date
:ie +
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 in and penalties of perjury.
Signature of Owner/Authorized Agent D , C)
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Total Permit Fee: $ /
Less Application Fee: 00"--
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Other $ Amount $
Remaining Balance: $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: _
. M. W-wt_ ` .Nr-t�C_ f..�