The URL can be used to link to this page

BP-35855RESIDENTIAL ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE do NON-TRANSFXRAB1 1. Date plan reviewed: 2. 30 days to review period expires: 3. OK to issue date: 4. OK to issue subject to requested submittals (see project review worksheet): 5. DENIED (see project review worksheet): 6. HOLD reason: 7. HOLD subject to Zoning Board of Appeals action: 8. Comments: 9. Inspector's Date Applicant inform f above D e: l��v Timer�V �� Clerk(/ C�PBoard of Bc�arcl oOCon: Gritix. , >tlealth Comments: �ippenls 2 ° ❑FiGas gre nntn N K4C�ST?(+ a • Balance: $pC7V. Chief = Total Permit Fee: $_�©�.�.?� Less Application Fee $ 25.00 Remainin . . .... ......... ItECTJTRIS INS rz-, TOTAL FEE: �` Gross Area - New Construction total sq. ft. E" Yi Gross Area-- Alteration total sq. ft. ��a a �_ �� Zoning Review: Signature: Energy Report: Signature: /®®� Permit Issued To; Gj �» 9 �� C8 1() T 11 iibil Ii�1�lAI flfl1VI 1tifT %gKET( HEA. S �... w ® 00-� .m ®.m: em.e e m.. ��a_s Fire Chief: Signature: Board of Health: Signature: Conservation Commission: Signature: Other: Signature: Description of work being performed: I�l J� 1 ui:3�l:Z�7��1/•\►f.Y.Y11 1SIYIIIIq�� 1.1 Property Address: (t)- Nearest Cross Street: Subdivision Name: Total Land Area Sq. Ft.: 1.4 Water Supply (MGL c 40 § 54): , ,,Municipal ❑ Private Well SITE PLAN SUBMITTED: ❑ yes ❑ no 1.2 Assessors Plat t Number: Plat Lot 1.3 Historical District ❑ yes ❑ no Has application been submitted to the Historic Commission? ❑ yes ❑ no Date: 1.5 Sewage Disposal System: ❑ Municipal VOn Site Disposal System CAbldg.forms\Bldgapp.res.wpd Page 4 Rev. January 1, 2003 I CAb1dg.f6rms\B1dgapp.res.wpd Page 1 Rev. January 1, 2003 RESIDENTIAL 2004 RESIDENTIAL 2004 SECTIOI' TRDPERTYt}Y 1lfil lt� UltI t I I2E Alm) 'tl56 2.1 Owner of Record: -- S—� r��Q24 Name (print) Contact Address Phone Number 2.2 Authorized Agent: -T� 3ocrq Contact Address Phone Number Name (print) ®Lg �O11ti"STICIICII SEtZVIGES 3.1 Licensed Construction Supervisor: N t Applicable ❑ Licensed Construction Supervisor License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor: N t Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no If no, go to the next section! Are you claiming exemption from the requirement? ❑ yes ❑ no If yes, submit the required affidavit! Company Name R gistration Number (if none, state ❑ none❑) Address Signature Telephone E piration Date 3.3 For Residential Remodel Work Only NOT HAVE ACCESS PERSONS CONTRACTING WITH UNREGISTERED CONX-om TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration, One Ashburton 01, Boston, MA 0 108, (617) 727-8598 Owners Name (print) Signature by sigping the above, the home owner acknowledges that t e will be no eligibilty to the Guaranty Fund Date 3.4 Homeowner Exemption - One & Two Family Only FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR T IIEIR OWN PROJECT 109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Coni rol 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 ith the rules d regulations promulgated b buildings or structures, unless he or she is licensed in ac/suchmeowner the BBRS entitled Rules and Regulations for Licensing Construction Supervisors. Exception: Any Homeowner performing work fouildi Permit is required shall be exemp from the provisions of this section; provides that if a Homeowner engages a person(s) for hire to do such woh meowner shall act as supervisor. For the purposes of this section only, a "Homeownas follows: Person(s) who owns a parce 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 ached or detached structures accessory to s ch use and/or farm structures. A person who constructs more than one home in a two-year period shall not be cHomeowner. If you are applying under this section sign below: Signature: Your signature carries certain responsibilities, including but not necessarily limite 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) Workers 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 ❑ new construction* ❑ addition (energy report required) (energy report required) ❑ deck ❑ pool ❑ accessory bldg (shed/garage) * If new construction, please complete the following: ❑ alteration ❑ repairs ❑ chimney/ fireplace ❑ replacement window/door o other no. of windows_ doors_ (specify below) ❑ woodstove ❑ demolition (specify below): 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):_geAr- ❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): �o,X✓ ❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): ❑ Air conditioning - (separate unit) l ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: —'j' � 12 I�Z 1 2- 4 �V (L,oa-A 13Zx Sim(-v i p- ,�: *,,j Item 3 Phimhina Estimated Cost ($) to be completed by permit applicant 5. Total = (1 + 2 + 3 + 4) I *Estimated Total $ (please print) StFE A7114v� �- I, 6XA&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 I, Muck q� `/ 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 penalties of perjury. Signature of Owner/ Date C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January 1, 2003