BP-57321SECTION 8 -INSPECTOR'S REVIEWICOMMENTS
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:
Inspector's Signature:
Applicant informed of
I Comments:
-7
Total Permit Fee: $ / -5
I TOTAL FEE: / S
PLICANT NOTIFICA
Oy Time:
Less Application Fee: $25.00
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
.- D i I
r71
Date: / —;; T 0
7-
Remaining Balance: $
Permit Issued to:
cn
-T
. _
-wnrWriewA1
e.r•.T�r,u 44
1.1 Property Address: aZ 74 ROO< D DUA/DEf 1?cAd 1 1.2 Assessors Map & Lot Number:
Lot Area (sf.) 02 g� G 4 Frontage ,- ` �' Map eRE Lot
Required Provided
Front Yard
Side Yard
Rear Yard
1.4 Water Supply (MGL c40 s54):
Municipal ❑ Private Well
0 CONSTRUCTION PLANS
1.3 Historical District ❑ Yes ' No
H
Has application been submitted to the istodc commission?
❑ Yes ❑ No Date:
1.5 Sewage Disposal System:
❑ Municipal XOn Site Disposal System
■C TE PLAN ■. ENERGY REPORT
RESIDENTIAL
SECTION 2 -PROPERTY'OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record: ! ^ SOS
,B R f, cF ,5�v,eB�Ro ,a,�,��,�/E� CZ Xo !Po c /� O I9411V 1CWJr R19 ISO =390/
Name (print) r Contact Address Phone Number
/y!D v-7w /%i
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable
Licensed Construction Supervisor. License Number:
Address: Expiration Date:
W Signature: Telephone:
V3.2 Registered Home Improvement Contractor: Not Applicable ❑
Are you a Home Improvement 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
vIf Yes, submit the required affidavit!
Company Name: Registration Number (if none, state "none"):
Address:
Signature: Telephone: Expiration Date:
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.
Owners Name (print):
Signature:
B signing the a ove, 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 is section sign bel
Signature:
Your signature carries ain responsibilities, including but not necessarily limited to, general liability
-7 1
SECTION 4 COMPEN
WORKER'S SATION
Worker's Compensation Insurance Affidavit must be completed and s
affidavit will result in the denial of the issuance of the building permit.
Deck ❑ Pool ❑ Repairs ❑ Alteration
❑ New Construction* ❑ Accessory Bldg.
(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 BathsNo. of Baths
No of Bedrooms Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (spec
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specifi
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
❑ Air conditioning - (separate unit)
None of the above to be provided Fuel Oil _
❑ Hot Water. Gas Electric
Description of proposed work:
Item
1. Building IVA
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4) __.._.,...
(Please Print)
, as Owner of the
I
to act on my behalf, in all matters relative to work authorized by this 1
Signature of Owner
9,W , as Owner/Authc
on the foregoing application are true and accurate, to the best of my
Signed under the pains and penalties 0pe;p.
Agent
52
led with this application. Failure to provide this
Signed Affidavit Attached: ❑ Yes ❑ No
❑ Chimney/Fireplace
❑ Roofing/Siding
1
2
Other
ated Cost ($) to be
APRAPA)C
EOJ
❑ Woodstove/Pellet Stove
❑ Other
(Specify below)
❑ Demolition
(Specify below)
property hereby authorize _
permit app
—" Date
Agent hereby declare that the statements and information
tedoe and belief.
AQ moo
Date