BP-77599RESIDENTIAL ❑ Phased Approval (R106.3.3)
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Board of Health: Signature. Date:
Conservation Commission: rSignature: Date:
p.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of work being performed:
- SEcrioN StTE IN O-, - x
1.1 Property Address: `Q4tr-- d WOOPmQ—kW 1.2 Assessors ap & Lot N6mber:'
Contact Person: 1 �.� ---_ Map Lot
Phone Number:
1.3 Historical District ❑ Yes VrNo
Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑
❑ Municipal ❑ Municipal Altering more than 25% per side of building
dPrivate Well Site Disposal System Has application been submitted to the Historic Commission?
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❑ Yes ❑ No Date:
❑ CONSTRUCTION PLANS El SITE PLAN ❑ENERGY REPORT
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_ ONAZ
ED AGENT _
2.1 Owner Record:
Name (print) '
Contact Address Phone Number
2,2 Authorized Agent:.
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Name (print)
Contact Address Phone Number
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3.1 Licensed Construction Supervisor/Specialty License: -
License Number. ^ f5zzea
Company Name/Contractor Name:6w, MP,15
Address:
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G '7
Expiration Date:
MY
Signatur Telephone-fJ0157111V
3.2 Homeowner Exemption - One & Two Family Only Section 110.R5;1.3.1 Exception: 9!
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 you are applying under this section�sign below:
Signature:
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. -,. -
rovide this
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failuriyple
in the denial of the issuance of the building Signed Affidavit Attached:s ❑ No
affidavit will result permit.
_ =L GTI�iNS DE$CRIPTCO�133F=PlQ)?tff;�EDtORl�-�Cbeclt alVpplcable} r= _
- �? -
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Wood stove/Pe llet Stove
❑ New Construction* ❑ Accessory Bldg. -.❑ Addition Roofing/Siding Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Z Doors
I-] DEMOLITION (specify): b�#^J-! _T JVA&&!Tg�, W1A1_PVV,Vs
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facility Name: Al e Cki&w4s# Location:
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 No, of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity,_ other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
13 Hot Water: Gas Electric Fuel Oil Other
SEGTICIN fi .._SfIMATELQIYTRCJC716h( EOSF =a =
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4 Mechanical (HVAC)
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�S>GCTION 7�C OINhiE&ACi14
TIt3kilZATI(3N �-
�tQ be'_";�vmpleted �rfien ownQ�s �genf or co�raE�aF appG��or°burld�rt�perm�tj; - _ _ -
(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
SEGl ION'7B , t1WNEKl11?14ORIZ6fl AGENT. DEELAftQiTIOfW <, ,
I, pma4ftp. I -,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.
Si ned under t pains and penalties of perjury.
Si ature of Owner/Authorized Agent Date
cT[aHs oPF#CEiitSPCTOR`S �tOTEs = _
Less Application Fee: $ Remaining Balance: $�
Total Permit Fee: $
Other $ Amount $ J
Gross Area - New Construction total sq. ft.
Gross Area - Alteration tot sq. ft.
Permit Issued to: r[I-Jey- Llj
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