BP-55783I
SECTION 8 - INSPECTOR'S REVIEWICOMMENTS
1. Date plan reviewed:`"��`/
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: , /, 7� Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
SECTION 10 -OFFICE/INSPECTOR'S NOTES
91 Less Application Fee: $25.00 Remaining Balance: $ " -.
Total Permit Fee: $
Other $ Amount $
ITOTAL FEE: 't'
IPermit Issued to:
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. C1;G`
RESIDENTIAL ❑ Approval in Part (Per 780 C& R.5111.13)
S25-00 APPLICATION FEE IS NON UE-FUNDABLE A NON-TRANSFEItABLE
SgECTIONN, I SITE INFORMATION
1.1 Property Address: 11�5 �/ lNt�CJ 1.2 Assessors Map & Lot Number:
Lot Area (sf.) _ Frontage wD Map Lot _ -
Required Provided
1 3 Historical District ❑ Yes ❑ No
Front Yard
Side Yard Has application been submitted to the Historic Commission?
Rear Yard ❑ Yes ❑ No Date:
F
1.4 �j'U ter Supply (MGL cr40 s54): /-Sr
ewage Disposal Sy tem:
�/ Municipal ❑ Private Well On On Site Disposal System
❑ CONSTRUCTION PLANS
❑ SITE PLAN
❑ ENERGY REPORT
RESIDENTIAL
SECTION 2 - PROPERTY OWNERSVIP/AUTHORIZED AGENT
1 Owner Record: Il
' 1J
Name (print) C , act ress / Phone Number
2.2 Authorized Agent(' , ,� \
Name (print) i� J Contact Address Phone Number S
SECTION 3 CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Ev�� Not Applicable ❑
Licensed Construction Supervisor: License Number: CC-5 67)2JI-2 D
Address: ('l9(P Expiration Date:
Signature: Telephone:
mac)
3.2 Registeped Home Im rovement C ntra or: Not Applicable ❑
Mt) rr
Are you a H6wc.,
ome ImproV'Gvem t Contractor subject to (780 CMRA 10.R6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
l I' If Yes, submit the required affidavit!
Company Name: �° /,� `'�iG Registration Number (if none, state "none"):
Address:
Signature: Telephone: -a, { Expiration Date: }�lJ
3.3, For Residential RemodN 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
❑ 1 am a Homeowner performing all the work myself.
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
5108.3.5 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 fans 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
L/
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25)
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
SECTION 5 - DESCRIPTION OF OPOSED WORK (Check all applicable) '
❑ Deck ❑ Pool ❑ Repairs �Altern ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows _ Doors _ (Specify below)
*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 Other
ascription of proposed work:���
Vyawr
SECTI N 6 TIMATED CONSTRUCTION COST;,
Item
Estim d Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0+2+3+4)
SECTION 7A -OWNER AUTHORIZATION
(to be completed when owners agent or contractor applies for building permit) .
(Please Print)
I, as Owner of the subject property hereby authorize
act on my behalf, in all matters relative to work authorized by this building permit application.
Sign a of Owner Date
_SECTION 713 - OWNER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent hereby declare that the statements and information
/onhe
foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Date Signature of O Authorized Agent