BP-43555'S
1. Date plan reviewed:
2. DENIED (see project review worksheet):
N 8 - INSPECTOR'S
3. HOLD
Reason:
4. HOLD subject to Zoning Board of Appeals action:
Comments:
Date:
Date:
Date:
SECTION 10 - OFFICE/INSPECTOR'SNOTES -
Less Application Fee' 0 T Remaining
Total t Fee: $ Permit F : 0
ota _
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gro s Area - Alteration total sq. ft.
Permit Issued to:
SECTION 11'-`"ADDITIONAL COMMENTS/SKETCHES
SECTION 1'-SITE INFORMATION .
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1.1 Property Address: .P U
1.2 Assessors Map & Lot Number:
Nearest Cross Street:
Map _—��z� Lot ! -
Subdivision Name:
1.3 Historical District ❑ Yes ❑ No
Total Land Area Sq. Feet:
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.4 Water Supply (MGL c40 5):
❑ Municipal LL ivate Well
1.5 Sewage Disposal System:
Disposal
❑ Municipal C�-On S tei System
LI CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
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W
Z
LL
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0
0.
0
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RESIDENTIAL
SECTION 2 -`PROPERTY OWN ERSHIP/AUTHORIZED`AGENT
2.1 Owner Record:
Ste /lo; Sa n
Contact Address Phone Number
Name (print)
2. Authorized Agent:_ -.•-- � ""
Name (print) _ Contact Ad Tess Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervis(
Licensed Construction Supervisor:
Address: /
Address: 0,� &J U
T
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
License Number:
dExpiration Date: )
-? A7/ a
Are you a Home Improvement Contractor subject to (780 CMR-6)? j2! Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name:
Address:
Signature:ZZ14���T
3.3 For Residential Remodel Work Only
PILO
I Not Applicable ❑
Registration Number (if none, state "none"):
/0 9 YE17
Date: S/ /
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1A Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
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 Construction
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 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:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 4 = WORKER'S COMPENSATION INSUKANUt: ArrwAvr i tmvL c +mac s 4;J1
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: P Yes ❑ No
SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. `� Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Specify below)
(Energy report required) 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 Other
Description of proposed work: r ► �3 e
SECTION 6 - ESTIMATED CONSTRUCTION COST ' ,
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
"Acwo--�'
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total 0 +2+3+4)
� SECTION 7A OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print) )
[' as Owner of the subject roe hereby authorize /��Y ✓s?�l(�N
I, � � J.11� 1 property rtY Y
��'�'�
to act on behalf, in all matters relative to work authorized by this building permit application.
7my
Signature of Owner Date r
SECTION 7B'- OWNER/AUTHORIZED AGENT DECLARATION
as (B�ter/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.
/NAa
C:..V....�..ro of �etoeri�l l+il f77Pfr Al7Prlt Date