BP-48899SECTION
1. Date plan reviewed:
2. DENIED (see project review worksheet):
3. HOLD
Reason:
4. HOLD subject to Zoning Board of Appeals action:
Comments:
Time:
Date:
Date:
Date:
Cle
l; ,--fir-
SECTION 10 - OFFICEII NSPECTOR S NOTES
"7 C Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $ J
Other $ Amount $_
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gro Area - Alteration total sq. ft.
Permit Issued to: r �'
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
S25.00 APPLICATION FEE IS NON I1E-Ftr." ,NBLE & NON-TRANSFEIIABLE
O.K. TO ISSUE -SIGNATURE:
DATE.
...
Zoning District.
Proposed Use:'
Zone: ❑ ❑ B E3 A V
AgwferZo ne.
,❑
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED. ':"
❑ Board o❑Board of
Cons.
PW
' _ -
❑ Eec.Energy Report-"`,,
Appeals Health
Commission Affidavit
Card Sent;
Cut Off Follow up
❑ Fire
„❑ Ga s ❑ Planning'
"..
D Sewer Card ❑Water Card
❑Zoning ,. ❑Other''
Chief',
- ... Cut Off , ,Board
'� ",Cut Off,': : Cut Off
*REQUIRE . . .. :,. ..
S INSPECTOR'S REVIEW .BEFORE THE ISSUANCE OF "A PERMIT:
PA THE%NT�AL APPROVAL
Zoning Review:
Signature:
Date:
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
Date:
Board of Health:
Signature:
Date:
Conservation Commission:
Signature:
Date:
Other:
Signature:
Date:
Brief description of work being performed.
l
SEC TION 1'-- SITE I F RMATION
1.1 Property Address: r rn !
1.2 Assessors Map & Lot Number:
Nearest Cross Street:
Map 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 s54):
1.5 Sewage Disposal System:
❑ Municipal ❑ Private Well
❑ Municipal ❑ On Site Disposal System
❑ CONSTRUCTION PLANS SITE PLAN ❑ENERGY REPORT
RESIDENTIAL
" SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Own f Record:
I-q 401-
l J! q (
Name (print)
ContacAddr s Phone Number
2.2 hori/zed A �,,t: �'
Name (print)
Cont Address/ Phone Number
`
t�/C ?V.a
SECTION 3 -CONSTRUCTION
SERVICES--
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor:
License Number:
Address:
Expiration Date:
Signature: Telephone:
3.2 Registered Home Improvement Contractor:
Not Applicable
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If.Yes, s mit th required affidavit!
Company Name: il9 �✓ 41,06b
Registrations 4Number (if none, state "none"):
( / 3 �
Address: / (%�(i` 3J 4
Signature: Telephone: 2
Expiration Date: ! ® z
//
'�.3 For Resideln al Remodel Work Only
PERSONS COh RACTING 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
❑ I 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
109.1.1 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
� 6
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 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 ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. of 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
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: /IL
SECTION - ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
01) R
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total= 0 +2+3+4)
,
SECTION 7A'- OWNER AUTHORIZATION
(to by completed when owner's agent or contractor applies for building per i
(Please P )
1, °� ` e 0� VV (.�
, as Owner of the subject property hereby authorize
to act on my behArll. in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
I, v"t '
1 L , as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application ark true and accurate, to the best of my knowledge and belief.
Signed
under the painsand penalties of perjury.
e ..... ...
Signature of Owner/Authorized Agent Date
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