BP-77348RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON P.V,_FiF NE AniF.ir A, ianAT_rVIn A 1WQ1V1V" & "w w.
1.1 Property Address:43 / FllP4 L1(,Q` , 1.2 Assessors Map & Lot Number:
Contact Persom—DA0�Map_ Lot c z _
Phone Number: S. I— n�2
1.3 Historical District ❑ Yes ❑ No
1.4 -Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
Year Built
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5 /13
0 CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIRENTIAI
SfrCTiON 2=;PROPERTY61t4NERSHtP1AtlT1-tOR(ZED..
_
2.1 Owner Record: ,_-.�
�' � "�-560 -2,
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Name (print)
Contact Address Phone Number
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Name (print)
Contact Address I Phone Number
SEGTlDN 3. ;CUlVST12UC�ION.SRYICES _ -
3.1 Licensed Construction Supervisor/Specialty License:
License Number: ( .3
Company Name/Contractor Nam
T Gt
(40
Address: `Q Expiration Date:
LP V
Signature: --Telephone:
8.2 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:
u SEGTI�N, _ 3lVt}K£R'r~041V1+N5ArT131�tNS1fRAi�tE�4EFL[A�/17"{MGL 435Y
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failur t rovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: es ❑ No
SE�'CION S=1?ES!�FttPTt01V Qf= PFtQPC1�ED11V'QRK(Oheclt,ali�pplicat5le�z_ :_� _ �..�._
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding 'Replacemen indow/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 ❑ Dum('pster On Street
4 Facility Name: ��W� Location: n Q� A
*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
D
x
x
_SECTION 8 .ETIIVIATD GDNSTRIJCfIO�I COST _
Item , Estimated Cost ($) to be completed by permit applicant
1. Building
2, Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4) f
(Please nnt) r�n
I 0 k4 /XJ � � �, as Owner of the subject property hereby authoriz� 7� M 41
tD act on my behalf ' II matters relative to work authorized by this building permit application.
�: �... Date
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.
Date
Gross Area - New Construction total sq. ft. _
Gross Area - Alteration total sq. ft.
Permit Issued to:
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