BP-55857SECTION 8-INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: �f► Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Total Permit Fee: $
I TOTAL FEE:
IPermit Issued to:
Less Application Fee: $25.00
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Remaining Balance: $ —`p
RESIDENTIAL
❑ Approval in Part (Per 780 CMR.5111.13)
$25.00 APPLICATION FEE IN NUA lira-FUN"AISLE d& Nv�=1'sAA�r�t«usL�
DEPARTMENTAL APPROVAL,,
Zoning Review:
Signature:
Date:
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
Date:
Board of Health:
Signature:
Date:
Conservation Commission:
Signature:
Date:
Other:
Signature:
Date:
Brief description of work being performed-
SECTION 1 _-SITE INFORMATION
1.1 Property Address: z q� bo\ �U � �) 1 1GLJ 1.2 Assessors apt -Lot Number
Lot Area (sf.) Frontage Map Lot
Required Provided
Front Yard 1.3 Historical District ❑ Yes ''N0
Side Yard Has application been submitted to the Historic Commission?
Rear Yard ❑ Yes o Date:
1.4 Wa r Supplyipal (MGL c40 s54): 1.5 Sew a Disposal System:
Munic❑Private Well Municipal ❑ On Site Disposal System
77 a o — ( 35�
❑ CONSTRUCTION PLANS ❑SITE PLAN ❑ENERGY REPORT
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Owner Record:
5v,7 - aitj 7-
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
ILA L&I"
Name (print)
Contact Address Phone Number
-SECTION 3 = CONSTRUCTION
SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable 0
Licensed Construction Supervisor:
License Number.
Address: 1�,/// 7
Expiration Date:
Signature: Telephone:
3.2 Registered Home Imerovement Contractor:
Not Applicable 0
Are you a Home Improvement Contractor subject to (780 CMRA 10.R6)? krYes DNo
If No, go to the next section!
Are you claming exemption from the requirements? 0 Yes 0 No
If Yes, submit the required affidavit!
Company Name: AIX141,7f
Registration Number (if none, state "none"):
Address:
Signature: Telephone: S51f- �r-Vr_d I
2��
Expiration Date: 24
3.3 For Residential Rem el Work Only .1
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
0 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 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
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25)
Workers 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: 0 Yes 0 No
SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check 61( applicable) _Z
• Deck 0 Pool 0 Repairs 0 Alteration [I Chimney/Fireplace 0 Woodstove[Pellet Stove
• New Construction* 0 Accessory Bldg. 0 Roofing/Siding 0 Other
(Energy report required) (Shed/Garage) (Specify below)
• Addition window/door 0 Demolition
replacement
(Energy report required) o. of windows 1,,b 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
11 Air conditioning - (separate unit)
11 None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
Description of proposed work:
SECTION 6 ESTIMATED CONSTRUCTION COST -
Item
Estimated Cost to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
L)
5. Total=(1 +2+3+4)
SECTION 7A.- OWNER AUTHORIZATION...
(to be completed when owners agent or contractor applies for building permit)
(Please Prtqt)
l�fyJ—ex"o
1, fj�5poW as Owner of the subject property hereby authorize
to act on my be If,relative to work authorized by this building permit application. 2)13
_matters
Sig ture f Owner Date
-SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
I, 1,4 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.
Signature of OwnerlAgrized Agent Date 71