BP-54656TOTAL FEE:
Permit Issued to:
Gross Area - New onstruction total sq. ft.
Gross Area - Alter a ion total sq. ft.
ES _
Zoning Review: Signature:
Date:
Energy Report: Signature:
_ �
Date:
Fire Chief: Signature:
S
Date:
- Board of Health: Signatur
Date:
Conservation Commission: Signature:
Date:
Other: Signature:
of work being performed:
Brief description
ECTION 1 -SITE INFORMATION
1 Property Address:
ti'Qy C7 W��
1.2 Assessors Map & Lot Number:
_
Lot
TI✓ ed�tc.
Map
Ifs o Frontage
Provided rovided
1.3 Historical District ❑ Yes ❑ No
Front Yard
Has application been submitted to the Historic Commission
Side Yard
❑ Yes ❑ No Date:
Rear Yard
ewage Disposal System:
System
1.4 Water Supply (MGL c4 ):
❑ Municipal On Site Disposal
❑ Municipal Private Well
/ /s-, . ) 1.0
0 CONSTRUCTION PLANS
❑ SITE PLAN
❑ ENERGY REPOR
IV
. RESIDENTIAL
/
SECTION 2 - PROPERTY OWNERSHIP
AUTHORIZED AGENT
2.1 Owner Record:
4444-' Z67 - 6 33
Nam (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3- CONSTRUCTION
SERVICES
3.1 Licensed Construction Supery
sor:
Not Applicable ❑
Licensed Construction Supervisor:
License Number.
Address:
_.Expiration Date:
Signature:
Telephone:
3.2 Registered -Home Improvement
I
Contractor:
Not Applicable ❑
Are you a Home Improvement Con
ractor subject to (780 CMRA 10.R6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from th
requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name:
Registration Number (if none, state "none"):
Address:
Signature:
Telephone:
Expiration Date:
3.3 For Residential Remodel Work
Only
PARSONS CONTRACTING WITH I
JNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS Ca
I or write:
Home Improvement Con
ctors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
❑ 1 am a Homeowner perform
ng all the work myself.
Owners Name (print):
ignature:
the
b e, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
c�yisigning
Date:
3.4 Homeowner Exemption - One
Two Family Only
FOR HOMEOWN
5108.3.5 Licensing of Construction SuperJisors:
shall be engaged in directly supervising person
or structures, unless he or she is licensed in a
Supervisors.
RS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
rdance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
(Exception: Any Homeowner performing work
or which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner
e gages a persons) for hire to do such work, that
such Homeowner shall act as supervisor.
For the purposes of this section only, a "Hom
ere is, or is intended to be, a one or two famil
ne home in a two-year period shall not be cons
wner' is defined as follows: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
dwelling, attached or detached structures accessory to such use and./or farm structures. A person who constructs more than
dered a Homeowner.
If you are applying under this sectior
sign below:
Signature:
Y ur signatur
carries certain responsibilities, including but not necessarily limited to, general liability
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25)
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
SECTION 5 -DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace 0 Woodstove/Pellet Stove
❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows _ Doors _ (Specify below)
*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 r
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 uel Oil Other
Description of proposed work: p� T-_ ?,C„.),— E _-.
SECTION 6 - ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0+2+3+4)
SECTION 7A - OWNER 4UT ORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Ri t) _Z,
as Owner of the subject property hereby authorize < «_
to act orfmy behalf, in all matters relative to work authorized by this building permit application. IsCVQ / 61,{
c_O VZ_ i OZ
kSignatu�re
of wner Date
-'SECTION 713 - OWNER/AUTHORIZED AGENT DECLARATION
1 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.
Sign e under t e pains a d penalties of perjury.
Si atur of Owner/ thorize'd Agent ate