BP-94035RESIDENTIAL
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2.1 Owner Record:
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
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3.1 Licensed Construction Supervisor/Specialty Lic nse: License Number:
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Company Name/Contractor Name:
Address:Expiration
Date:
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Signatur6
3.2 Homeowner emption -One amily Only Section 110.R5.1.3.1 Exception:
R HO S WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception: Any Ho wrier 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:
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
xrbt _es�zr�rtory ,orate° uQ�zx r» ail r�r�r r
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❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition Roofing/Siding ❑ Replacement window/door
No. of windows Doors
(Energy report required) (Shed/Garage) (Energy report required) —
❑ DEMOLITION (specify):
L!~ .ation of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Faci`ity 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
❑ Hot Water: Gas Electric Fuel Oil Other
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Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5 Total 0 +2+3+4)
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(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.
Signature of Owner Date
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as Owner/Authorized Agent hereby declare that the statements and information
on th 'foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under t I a penalties of perjury.
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Signat her/Auth zed Agent Date
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: 'E
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RESIDENTIAL ❑ Phased Approval (R106.3J)
.92 r-00 APPLICATION FEE IS NON BE -FUNDABLE & NON -TRANSFERABLE
1.1 Property Address: ,IX __?ZWZ1 !>t 2rw�� �-�- 1.2 Assessors Map &Lot Number.
Contact Person:Map Lot -
Phone Number:`
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
1.3 Historical District ❑ Yes ❑ No
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
CONSTRUCTION PLANS El SITE PLAN
ILJ HF A 5 'e.'Mevised 5 /13
ENERGYLJ REPORT