BP-76600RESIDENTIAL ❑ Phased Approval (R106.3 3) `
$25.00 APPLICATION FEE IS NON BE-FUNBABLE A NON -TRANSFERABLE
1.1 Property Address: &5, %%Aaw if l L. -1:31a ¢-P
Contact Person: -'OE L A-V I L,},
S�/� Phone Number: L%o
1.4 VWer Supply (MGL c40 s54): 1.5 Sewage Disposal System:
nicipal 70nSlite
icipal
❑ Private Well Disposal System
1.2 Assessors Map & Lot Number: p
Map a Lot
1.3 Historical District ❑ Yes n No
Year Built
❑ Altering more than 25% per side of building
Has application been sub%itted to the Historic Commission?
❑ Yes Q No Date:
Revised 5 /13
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTIG" TY.OWNERSHIP1AUTHORIZED
AOtNT -
2.1 Owner Record:
J�� q`I 2C9 373
v a EL -
Name (print)
A-l`T
Contact Address Phone Number
S E
/om Poll /fl LL R 0
%s
2.2 Authorized Agent:
Name (print) CrU EL U J LA
Contact Address Phone Number
'
/�
(a PA-1 PON 141 Q, P0410 6-0 5" ,2 03?
,. `SECTION " COhISTRtICTION StRYIGES
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name:
Address:
Expiration Date:
Signature: Telephone:
3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 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 you are applying under this section sign below:
Signature:
_ ECTIOiN 4.'-"Wt?RFfER`S C(iMPE111SA1,IQN.lNSt1RANGE At=1[?AVI1'INGL c`M'S2 §:25 ... 4
Wor-'(er'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 )KQNo
Sl✓CT(C3N 5 bESCRIPT(O1V OF'FRt?POEb WORK (check a1I aplica6leJ
❑ Deck ❑ Pool ❑ Repairs LrYAlteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (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
❑ Fumace (hot Mr) - 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
Item Estimated Cost ($) to be completed by permit applicant
1. Building Sz),ov
2. Electrical i c�cU
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4) - z .0a
(Please Print) t�
ci U6 L as Owner of the subject property hereby authorize/��#' ��z7 rc
to act on my behalf, in all matters relative to work authorized by this building permit application. so
2 L2 (, �45
Sign a of Owner Date
l JCE L• 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.
Signed under the pains and penalties of perjury.
�7 I Less Application Fee: $25.00
Total Permit Fee: $ l
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
C L�J &+T � )0 q
iTLF�'tL UT U 5-3"
POL-le-Y'No -#-/40/aao33�'
N
Date
Remaining Balance: $ -� �•