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d address Q Engirteering ET Cioss
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Cl Fire El Gas ❑Electric Other
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6EPARTMENTA APP'ROVAE
Board of Health: Signature:
Date:
Conservation Commission: Signature:
Date:
DPW.: Signature:
Date:
Fire Chief: Signature:
Date:
Other: Signature:
Date:
Brief description of work being performed: ti S A LL-
(141 Re > t m d o `u s
S C1•t0f ;1=StT� WOW-
1.1 Property Address: 3 (%des l�f� C -
1.2 Assessors Map & Lot Number:
Map Lot �---
Contact Person:
Phone Number: ,qC (— 1 Z Sf—�i,�Z) O
1.3 Historical District ❑Yes ❑ No
Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑Altering more than 25% per side of building
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5/13
❑ CONSTRUCTION PLANS 0 SITE PLAN 0 ENERGY REPORT
Estimated Cost ($) to be completed
RESIDENTIAL - -
SECTION Z - PROPERTY OWNERSHIP/AUTHORIZED AGENT„
2.1 Owner Record: MA .,)-0,__ Contact Address Phone Number
Name (print)
2.2 Authorized Agent: • � ,xQ ` 2,E S f y 2, - Se
_ 'Contact Add fess Phone Number
Name (print)
3.1 Licensed Construction Supervisor/Specialty License:
Company Name/Contractor Name: 1,At iC 1(,
Address: Leo �!-1 �,v�h �,i► ' i
"7cla
License Number:
Expiration Date:
7" Y-11
Signature } Telephone: Z l
3.2 Homeowner Exemption - One & Two Family Only Section 11Q.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: Persons)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:
lEJDf�sYYNR[lE[az VVvl�i�{y.«�.rr1.1.-..:.•-: _.-:-.— --z-. -. .. -... - -
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: Ffyes ❑ No
- S OCfftOEOF . RK5 ...
TIONflEhec alfap�s[�cabte} _ _
❑ Deck ❑ Pool
❑ Repairs
❑ Alteration ❑ Chimney/Fireplace
❑ Woodstove/Pellet Stove
❑ New Construction"
❑ Accessory Bldg.
❑ Addition ❑ Roofing/Siding
LT Keplacement window/door
No. of windows Doors
(Energy report required)
(Shed/Garage)
(Energy report required)
_
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site
Facility Name: Location:
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
❑ Dumpster On Street
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
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5, Total =(1+2+3+4)
6ECT[Oft 7A OWNER REtiHORIZAT(QI'j - ermit
_ "({o be ct�nplefed when owner's agent or contractor applies fof buitdln p - l
Please Print) authorize
. as Owner of the subject property hereby Y
I, p Ilcation.
to act on my behalf, in all matters relative to work authorized by this buildingpermit app
, _ .^1-�iCcGY��CY t�+��4�Cr� Date
Signature of Owner
= SEGTIUt -4ts
t as Owner/Authorized Agent hereby declare that the statements and information
1, Ci f1 ��r^<^' S
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pain and penalties of perjury.
Gross Area - New Construction total sq. ft.
Gross Area - Alterc,
Permit Issued to:
Less Application Fee:J2<0O
Other $ Amount $
a
Remaining Balance
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