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BP-95044I L 0 Phased Approval (R106.3.3) .00 APPLICATION FEE IS NON RE -FUNDABLE & NON -TRANSFERABLE Contact Person: WIX WON JLJ He � 5 ARjP-revised 5 /13 0 CONSTRUCTION PLANS Ili SITE PLAN ENERGY REPORT RESIDENTIAL x Sf=CTlOhf i'R(3 T'3lNN.ERSHIP AlITHO IZEQ AO [Vt. 4 Owner Record: J500C ` 41(00 I)u�t R�cd s f Name (print)AV) �V3 Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number '�� 3.1 Licensed Construction SupervisorlSpecialty License: License Number. Company Name/Contractor Name: � o C Address: Expiration Date: Signature: Telephone: 3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception: i 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. E If you are applying under this section sign below: Signature: a - u:Ii. 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 ❑ Deck ❑ Pool ❑Repairs ❑ Alterati�^, ❑Chimney%t irepla vI Woodstove/Pellet Stove ❑ New Constructicn'� ❑ Accessory Bldg. Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (Shed/Garage) X(Energy report required) No. of windows Doors ❑ DEMOLITION (specify): Location of debris removal (per MGL CA 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 T d G' tF1Ut . Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5 Total 0 +2+3+4 OUtr h0.00 .N O NEB � -�tto,be �a�tp�efe�iitterYo�n�r'S��en�oF�coiEt�cto��P ��:_ � `` `� `� fsf�g�o7`�yi�ct�rifsefmit� � (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 �. iB, EiWNEE/AUTtE3RIZED �1�EN1 QECLARATiUN " , ..31S.EGT(!3N ISQGC` �tpQll(U , 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. Z�Z�/ZUZt� Signature of Owner/Authorized Agent Date k _� zECTfON ti (IFFt _ P01111 Total Permit Fee: $ - j � j Less Application Fee: $25.00 Remaining Balance: $ Z Other $ Amount $ Gross Area - New Construction total sq. ft. — 9'0 9_ Gross Area - Alteration total sq. ft. Permit Issued to:� �zr D �O i ✓� " �i �' mac.[ ��l t2v'd :- 4 a x !.ca,.S rt�. . , 3 �- 35 z,-rs`' � ? :. - E-�'44 !t^� .C� i s i©,} • k ip n`" -t ,cy .. r'-• _�l,'(X J 0 D, (a✓ tart e with Q v �-eJ 4 � 5 th 56-9� � e awrwc house b rea ewc'y Ctovpwd) . i