BP-58876`SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed: JAN 0 8 2010
RESIDENTIAL 0 Approval in Part (Per 780 CMR. 5111.13)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE A NON -TRANSFERABLE
2. DENIECi'(slee.'project revi*ewworksheet):
Date:
3. HOLD
; Reason: Date: JAN 0 8 2010
4. HOLD subject to Zoning Board of Appeals ctiqr(—)�A Date:
Comments:
I Inspectors Signature:
Date: JAN 0 8 2010
SECTICIN 9 -
APPLICANT NOTIFI
PATION,
Applicant informed of above:
Comments:
Date:
/,//)I)D
Time:
U Clerk:
SECTION 10 - OFFIWI NSPECTOR'S NOTES
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: /-)z> I
SECTION 11 - ADDITIONAL COMMENTSISKETCHES
ee ex�..,
2
SITE MEPRMATION
Property Address:
1.2 Assessors Map & Lot Number:
Lot Area (s f.) 417 AC FZ, Frontabe *:r, JQQ 0sJ—f4(dWAXA-f—
Map 7,'-f Lot �
Required Provided
Front Yard
1.3 Historical District 11 Yes 0<0
Side Yard
Has application been submitted to the Historic Commission?
Rear Yard
0 Yes 0 No Date:
1.4 WJe1r Supply (MGL c40 s54): L-1 0 U Ju is
/5 Sewage Disposal System: jUO Ze ")AA P_
Municipal 0 Private Well
0 Municipal 0 On Site Disposal System
❑ CONSTRUCTION PLANS SITE PLAN ❑ENERGY REPORT
an1iffl-p"
i
SECTION 2 - PROPERTY OWN
ERSH /AUTHORIZED AGENT
2 1 Owner Record:
GrU.St�-J tr i4l A2A
!�Wq: Row
A�t.t7 u
-
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3'-'CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable
Licensed Construction Supervisor:
License Number:
Address:
Expiration Date: t
Signature: Telephone:
3.2 Registered Home Improvement Contractor:
Not Applicable 0"
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name:
Registration Number (if none, state "none"):
Address:
Signature: Telephone:
Expiration Date:
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA "02108, 617-727-8598
am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner cknowledges that there will be no eligibility to the Guaranty Fund
r►
Date: Lza:: �0ni
11
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
shall be engaged in directly supervising persons engaged in construction, "reconstruction; alteration, repair, removal or demolition involving the structural elements of buildings
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 Construction
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 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:
Your signature 6brries certain r ponsibilities, including but not necessarily limited to, general liability
V
II
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25)
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 2rNo
SECTION 5 -DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) cify be
CEO]
❑ Addition ❑ Replacement window/door olition
(Energy report required) No. of windows _ Doors cify belo
*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 ( s
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
escription of proposed work:
VY1p t T ! 7U L
SECTION 6 - ESTIMATED CONSTRUCTION COST .
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = 0 + 2 + 3 + 4)
SECTION 7A -OWNER AUTHORIZATION , -
(to be completed when owners agent or contractor applies for building permit)
(Please Print)
'
I, , 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. Date
SECTION 713- OWNER/AUTHORIZED"AGENT DECLARATION
I, as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application re true and a curate, to the best of my knowledge and belief.
Signed under t e pai -and penaltl s of perjury.
Sfpature of Owner/Autho gent Dat
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Y
SCOT 4its Erdorsed
r a
1 €4 ", Fe wept On Site
iDuring, Constructian
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