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BP-93773RESIDENTIAL :;,SECTION 2 =_PR9 t RTiC©aIVNERSHIPJAUTHORIZED AGENT _ Sees -- l 2.1 Owner Record: Y Q)-) Name (print) Contact Address Z Phone Number 2.2 Aut o it zed Age ���• � t � FS~"i IE—ck gam-- H l_ t Name (print) Contact Address Phone Number ' � _ - - SECTION_3 � CON;STRUG"ilON SER�tICES , ._.-_ 3.1 Licensed Construction Supervisor/Specialty License: License Number: Company Name/Contractor Name:v i V i ot a V— #TeuUx Address: S 1-c, SSA -am i fh IA � pir tion Date: Ir c Signature: Telephone:a,�..� 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 of 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: __ ;,�- >_SECTiC11N-�IUQEtiCER'��OIVlPENS'ATfON 1N$llRANC� �iFFi[?AN1T (MGL�;'I52 �25) _ '' � � � _�- .= Wor'ker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to pride this affidavit will result In the denial of the issuance of the building permit Signed Affidavit Attached ❑ s ❑ No -. 7= _ _ _ <-,._ j.SE�TIOPiS 'DESCF2t17'fON .. PROP05ED 11VORK ��hea(z�11}pltca(j _. ❑ Deck ❑Pool ❑Repairs ❑ Iteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Cor struction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy re ort required) (Shed/Garage) (Energy report required) No. of windows_ Doors ❑ DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street Facility Name: Location: *If new construction, please complete the following: Single Family: No. of Bedrooms No. of Baths Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 No of Bedrooms Unit 2 No. of Baths Unit 2 ❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): ❑ Air conditioning - (separate urit) ❑ None of the abor4 ,..- d 13 Hot Water: G$O Electric Fuel Oil Other SECTION-' = ESTIMATECI CNSTRUCTIDi�I,CQST r' Item Estimated Cost($) to be completed by permit 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1+2+3+4) SECTION 7A' OWN ER A[fTFIOl2lZATION (to be r o�ripletecl nrhen'oinrner`s agenf-or contf_acfot• applies for build ng pe" MK (Please Print) I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. aches CIO Signature of Owner Date I, 'C/ I • --lV1_4 1161 ni' wned uth ized Agent h eby declare that the statements and information on the foregoing application are true and accu e, to the best of Trtk6knewfelge and belief. Signed under the pains and penalties of perju I Signature of Owner/Authori d Agent Date SECTION $=`OFFlCEnNSPECTOR'S NOTES: Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued to: i% /� /� ? I PC1YL /2G�65 ® ,6e L C� f _> -: - SECTION 9 ,4ESRlPiO�I flF WOttK BEi[� PE(dRlli]l±E3. A...n ... __ RESIDENTIAL ❑ Phased Approval (R106,3.3) $25.00 APPLICATION FEE, IS NON BE-FUNDAISIX, Jk NON-TRXNSFERAOLE Contact Person: lCG�111��(lLl..� ,,, Revised 5 /13 ❑ CONSTRUCTION PLANS 0 SITE PLAN ® ENERGY REPORT