BP-606172.2 Authorized Agent:
Name (print)
Contact Address
�..'(-- jC-1-. j`c Z
Phone Number
Phone Number
3.1 Licensed Construction Supervisor/Specialty License License Number:
Company Name/Contractor Name:
C Address:
Expiration Date:
0 Signature: Telephone:
P 3.2 Registered Home Improvement Contractor:
Y Not Applicable ❑
® Are you a Home Improvement Contractor subject to (780 CMR.11JOYesF Are you claming exemption from the requirements? ❑Yes ❑N
L If Yes, Go to Section 3.3
Company Name/Contractor Name: Registration Number (if none, state "none"):
L Address:
ErFRe
Telephone: Expiration Date:
Nential Remodel Work Only
CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
EOR COMPLAINTS call or write:
(S)me Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA. 02108, 617-727-8598
a Homeowner performing all the work myself.
Owners Name (print):
I Signature: v
y signing th bove, the ho wner acknowledges that there will be no eligibility to the Guaranty Fund
Date:._/ /r
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building
or structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Constructioi
Supervisors.
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 Homeowne
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 whic
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 tha
one home in a two-year period shall not be considered a Homeowner
If you are applying under this section sign below:
Signature: �/,o ,AI
rpOnature catdes certain responsibilities, including but not necessarily limited to, genera
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
❑ Deck ❑ Pool
❑ New Construction*
(Energy report required)
❑ Addition
(Energy report required)
❑ Repairs ❑ Alteration
❑ Accessory Bldg.
(Shed/Garage)
❑ Replacement window/door
No. of windows Doors
'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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil
on of proposed work:
❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
,''Roofing/Siding ❑ Other
(Specify below)
❑ Demolition
(Specify below)
Other
(Please Print)
1, , 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
I, ,4JZrt40 t"'t' F&A , 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 p alties of perjury.
14
Signature of O er/Authori Agent 7
Date
Page 2
Page 3
✓^ SECTION.?.- INSFE�,TO 'S R�'JIE� �ICOf�it' ENTS.77,7777,777
1. Date plan reviewed: AUG 0 5 2010
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: ZzLnn4 Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: Date: AUG 0 5 2010
EC ,lOV i�PPL[GAIlT, fitOT(FICATION4,r
s
Applicant informed of above: Date: Time: r% Clerk:
- -
Comments:
SECTIC3fd :4 f)FF;,ICE/,►NOPECiTOt '3„1 d zt
y�
Less Application Fee:O
Remaining Balance: $
Total Permit Fee.- $
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteratio total sq, ft.
Permit Issued to:
RESIDENTINA1 ❑ Approval in Part (Per 780 CMR.5111.13)
.1 Property Address: i N S LA D I-S F4&wk, Oi AJ
Lot Area (sf.) Frontage
Required Provided
Front Yard
Side Yard
Rear Yard
1.2 Assessors Map & Lot Number:
Map Lot
1.3 Historical District ❑ Yes ❑ No
Year Built
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
Municipal Private Well ❑ Municipal ❑ On Site Disposal System ❑ Yes ❑ No Date:
CONSTRUCTION PLANS 11 SITE PLAN El ENERGY REPORT
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4oro7
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