BP-62368Inspector's Signature:
�f SVQ 10,'N 9 APPLICANT ItiIOT[FICATiON
Applicant informed of above: Date: l � Time:
r
Comments:
All I
`] Less Application Fee: $25.00
Total Permit Fee: $ L
Other $ Amount $
TOTAL FEES Gross Area New Construction total sq. ft
:Zs,
ss Area - Alteration total sq. ft.
Permit Issued to:1T7��
1�
i
DatEEB 15 2011
El Approval in Part (Per 780 CMR.5711.13)
y"0,
"SEGTIOR41t,E,SITE, INFQRMATION
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1.1 Property Address: !9 �(��`(l71�� �ci 1.2 Assessors M p & of Number.
Lot Area (sf.) Frontage Map Lot_
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard
Rear Yard Year Built
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System ❑ Yes ❑ No Dater
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® CONSTRUCTION PLANS ❑ SITE PLAN ® ENERGY REPORT
Page 1
RESIDENTIAL
2.1 Owner Record:
k:Na—me (print) Contact AddressPhone Number
Authorized Agent:
Name (punt)
Contact Address f., P_ipne��lumber
3.1 Licensed Construction Supervisor/Specialty License : License Number: c3
Company Name/Contractor Name:
C Address: e�" rc�
CExpiration Date: L/r/
P
0 Signature: Telephone:
Y 3.2 Registered Home I rove nt Contractor: Not Applicable ❑
O Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No
F Are you claming exemption from the requirements? ❑ Yes ❑ No
(. If Yes, Go to Section 3.3
Company Name/Contractor Name: Registration Number (if none, state "none"):
C Address:
E Signature: Telephone: Expiration Date:
I�! . 3.3 For Residential Remodel Work Only
C PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
E "QUESTIONS OR COMPLAINTS call or write:
(S) Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
❑ I 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:
r3.4omeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
.5 Licensing of construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
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 by the'BBRS entitled Rules and Regulations for Licensing Constructioi
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 Homeowne
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 whic
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 the
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
Page 2
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
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration himney/Fireplace 1, F&Oodstove/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
Decrip/Ition of proposed work:
Other
RM
Item Estimated Cost ($) to be completed by permit
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 +2 + 3 +4)
.-
I-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.
L;_Z
Sig ature of Owner Date
I
I, ! / d as Owner/Authorized Agent hereby declare that the statements and informat
ion
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
gnature of
Agent
Date '
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