Loading...
BP-83428L0CcLk0r) ©F fin" \r)pw\-z I S�- 1-�v•2` �� S u nt ess w�� -FayCIZ N6 � C �mm Vim- S ckvoc) . RESIDENTIAL ❑ Phased Approval (R106.3.3) $25.00 APPLICATION FEE I51l ON nF.uYrvn®uu.w .z 1.1 Property Address: a Ph rm ('sz � ��� 1.2 Assessors Ma Lvt Number: Contact Person: Map Lot Phone Number: odd 3 q t oaM C�!-ly t 2tl Cnq.-7/-7 , 7/- 01/_ it2,.r:..i .LL 13 f; t 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal XPrivate Well XOn Site Disposal System is oncal DIsL, cE ❑ Yes No Year Built ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: Revised 5 /13 ❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ Fru�Qr_v Qe0nr5 RF-QInFNTlel Estimated Cost ($) to be completed by permit applicant SECTION 2P00PEkTY�tN[d1ERSH1P]AU fHORIZED AGENT „ s 2.1 Owner Record: kA ���2 A a03 - C no _use Name (print) Contact Address Phone Number 2.2 60thonzed Agent: L � dl, Oc AS a( ,rr> c e I u) ao3.9 i o ffs 9 s Name (print) V su m l C0a 6 Lt C Contact Address Phone Number -� `, _-SECTION 3 GONSTRU�TION SERVICES s 1i.53 3.1 Licensed Construction Supervisor/Specialty License: Licens Number: Ll � # ° Company Name/Contractor Name: Address: Expiration Date: Signature: Telephone: 3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 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: IAfOROM N ITI_MGL 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 - f z�S�T10N_5'=E?ES�RtP,r101V OF.PROP'aSEDNfOEtK_�Chectc�Ifappltcable} , _._--'� - .,:�� '£ �' ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows _ Doors _ ❑ DEMOLITION (specify): Location of debris removal (per MGL C.40 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 11 Hot Water: Gas Electric Fuel Oil Other 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total =(1+2+3+4 (P] I e - ase Print) Li r I � , as Owner of the subject property hereby authorize to act on my behalf, i all matters relative to work authorized by this building permit application. Dat of Owner X. Eduo a� Wte as Owner/Authorized Agent hereby declare that the statements and information egoing ication are true and accurate, to the best of my knowledge and belief. Signed and the pains and penalties of perjury. / onature of Owner/Aut Ize gent Date Total Permit Fee: $ Less Application Fee: $25.00 Other $ Amount $ Gross Area - New Construction total sq. ft. rrnss Area - Alteration total sq. ft. . W,L Permit Issued to: Remaining Balance: $ REsOi�►RT11 _8, 51KAIV G1 --P P- bilklV�icD vww-� A c� q C_OnSv�t' v-\ f� a C�-Q9 � � �C� r � V�Si chi- �''�''L1 a �\ no M 5 a n to \ « S t Cam. Pi%llrun (C-