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BP-84940a RESIDENTIAL 0 Phased Approval (R106.3.3) F y S25.00 AprLILAnON FEE IS NON BE -FUNDABLE & NON.TBANSFERABLE 1. 1 Pfop rty AddressW'r' y, ��—� � 1.2 Assessors Map & of Number - or", t Person: Tl � e, .. Map Lot /one (Number: 1.3 Historical District ❑ Yes M No 1.4 ater Supply (MGL c40 s54). 1.5 Sewage isposal System: Year Built ❑ Municipal ❑ MLmIcipal ❑ 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: Revised 5 /13 M CONSTRUCTION PLANS VIRITF PLAN Ili 1=N1=Rry orzon®-r RESIDENTIAL SEt;T10N PROFi=Ftf Yt3WLV€RSI`11P/�1 T(IOR( ED A�EN.7 _ 2. Owner Record: Name (print) Contact Address Phone Number 2.2 Authorized Agent: IName (print) I Contact Address 3.1 Licensed Construction Supervisor/SpecialtyLicense: LicCeSns CSSd. Number: Company Name/Contractor Name: �' o Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1+2+3+4) ©G� Phone Number (Please Print) 1, 1 as Owner of the subject property hereby authorize 21-4—M—d I I I to act on my behalf, in all matters relative to work authorized by this building permit application. Address: Expiration -Date: Signature: Telephone:" � F 3.2 Homeowner Exemption - One & Two Family Only Section 110.135.1.3.1 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 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 y are applying under this section sign below: 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 77 DESGRtRX, i3F F'R61�� t WOt€] �Gi eetE ({a�pltcable ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ ccess ry Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) Shed/G age) (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 unit) ❑ None of the above to be provided ❑ Hot Water. Gas Electric Fuel Oil Other Signature of Owner Date r• SECTION 7B=� OWNEIf1aUTHilRIZE❑ AGENTpECLARA'T(ON ' 1, r e , as Owner/Authorized Agent hereby declare that the statements and information tfie foregoing application are true nd accurate, to the best of my knowledge and belief. Si ed under th pains and penalties of perjury. ;inngh ire of Owner/Authorized Aaent Dat Less Application Fee: $25.00 Total Permit Fee: $ Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area -Alteration tofi I s . ft. Permit Issued to: 3 a, 46�/ Si Remaining Balance: U:\F'KUJtLI Z)\UAKI IVIUU I Fi\KUI,R U UUIVUtt KU\I//4U1V1 Duuuam O! YURUT \b-CPWt,\JCY I K--DHJC.uwt;