BP-64586RESIDENTIAL
0 Phased Approval (R106.3.3)
1.1 Property Address: eQ I Q : 11.2 Assessors Man & Lot Number:
ILA
Lot Area (sf.) l�L� Frontage qcl Map Lot-�
Required Provid �A nn n
Front Yard �� 1.3 Historical District ❑ Yes ❑ No
Side Yard cr'alZ $b+ -i%
Rear Yard „ gyp, Year Built
❑ Altering more than 25% per side of building
1.4 Water Suppl�(M c40 s54): 1.5 Se age Disposal System: Has application been submitted to the Historic Commission?
❑ Municipal [ Well EWunicipal ❑ On Site Disposal System ❑ Yes ❑ No Date:
Rpviseri 1n/11
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION 2-'IPROPERTY OWNERSHIP/AUTHORIZED
AGENT
1 Owner Record:
S3 �°
''� r. �cl�.l�e.. Nt� rG�r
✓ anexr) lse i-) r-v
Name (print)
Contac ddress
Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION
SERVICES
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 110.135.1.3.1 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: '
SECTION 4 = WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25) .,
Vilorker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to pro ' this
affidavit will result in the denial of the issuance the building
of permit. Signed Affidavit Attached: es ❑ No
SECTION 5 '.DESCRIPTION' OF PROPOSED WORK (Check all applicable) <'
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding /Other
I
(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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other