BP-48417SECTION,8 -INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Date: Vz'-
=CTI 9''-`APPLICANT NOTIFICA
73/U Time: — /
SECTION 10 -
OFFI E/INSPECTOR'S`NOTES
Less Application Fee: $25.00 Remaining Balance: $ d�
Total Permit Fee: $ 0,0
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.T—
Gross Area - Alteration total sq. ft.
Permit Issued to: tl C) Al G -' o �) oy n /°!9 c+ i p /�iP C� f'if <7 i �/ /� ,� ✓7 �� iZ
SECTION 11-ADDITIONAL COMMENTS/SKETCHES
Foot. lq'rC-r9
10/,�' ry?
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
Zoning Distrct:
% Proposed Use Zone: [YC ❑ B ❑ A ❑ V.'
Aquifer Zone.
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED;«
❑ Board off
Board of Cons F❑ emo ❑DPW
❑ Elec.
❑Energy Report
;Appeals Health Commission Affidavit Card Sent
-.
Cut Off
Follow up'
ire
O Gas = ❑ Planning " ❑ Sewer Card ❑Water Card `'
❑Zoning
❑Other '
Chief
Gut Off Board Cut Off . ;' Cut Off
"REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL ".
Zoning Review:
Signature:
l
Date: /
O
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
Date:
Board of Health:
Signature: `'
Date:
Conservation Commission: J Signature: _° •' * V (
Date:
Other:
Signature:
Date:
Brief description of work being performed:
SECTION 1 - SITE INFORMATION
1.1 Property Address: M LL RIN
1.2 Assessors Map & Lot Number:
Nearest Cross Street:
Map 2.q Lot Sq i
Subdivision Name:
Total Land Area Sq. Feet: .S,J I�iCJQ��
1.3 Historical District ❑ Yes K No
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.4 Water Supply (MGL c40 s54):
1.5 Sewage Disposal System:
1AMunicipal ❑ Private Well
❑ Municipal XOn Site Disposal System
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
r
RESIDENTIAL
SECTION 2 - PROPERTY OWNE
D AGENT
2.1 Owner Record:
dos a PeklEI R(1 23 AiRMk) B1LR� �"� �- 49Y-,y',fba,
Name (pant) Contact Address
Phone Number
2.2 Authorized Agent:
%,4AAr1%QJT14 86c)" 1%Q NF 104A5Asi Name (print) Contact Address
. $ - q%- 710 Phone Number
SECTION 3 `CONSTRI IrtTit-W CG0111rrcc
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor: (Q K XVIES,S&d
Address: $'frp 44 1 ,L2; S4kn- -g Id &AAF6,12Z dfi
Signature: Telephone:5o6_�r9k-7/�
Z 3.2 Registered Home Imp vement Contractor:
W
VAre you a Home Improvement Contractor subject to (780 CMR-6)? XYes ❑ No
If No, go to the next section!
LL. Are you claming exemption from the requirements? ❑ Yes XNo
n
Not Applicable ❑
License Number:
Expiration Date:
Not Applicable ❑
If Yes, submit the required affidavit!
aCompany Name: / AC Registration Number (if none, state "none"):
O Address: $-1wi- Yoke-491407 109 81a. +1
r Signature: Telephone:5d -9?e-f7lbe Expiration Date: wxq o i
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
❑ I am a Homeowner performing all the work myself.
i Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
' Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 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 carries certain responsibilities, including but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 4 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c152 &'251
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
stc I IUN 5 -;DESCRIPTION OF PROPOSED WORK (Check all al
❑ Deck IKPool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace
❑ New Construction" ❑ Accessory Bldg. ❑ Roofing/Siding
(Energy report required) (Shed/Garage)
❑ Addition ❑ Replacement window/door
(Energy report required) No. of windows _ Doors _
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
of
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1 +2+3+4)
7
Other
TED CONSTRUCTION CO
Estimated Cost ($) to be
❑ Woodstove/Pellet Stove
❑ Other
(Specify below)
❑ Demolition
(Specify below)
a
Please Print) ,
1, X, ED r RA , as Owner of the subject property hereby authorize
tIltdoneh
al in all matters relative to work authorized by this building permit application.
ure of Owner
Date
t - vrv,vr-rvAU 1 r1UKlctU AGENT DECLARATION_
I' VD Q�� as$ms�e /Authorized Agen ereby declare that the statements and information
on the foregoing application are true and accurate, to the best o ge and belief.
Signed under the pains and penalties of perjury.
Signature �Owne thorized Agent - - iq - 7 V
Date