BP-70465RESIDENTIAL
SECTION 2'- PROPERTY OWNERSHIPIAUTHORIZEDAGENT
2.1 Owner Record:
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Contact Address
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Name (print)
Phone Number
2.2 Authorized Agent:
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Name (print)
Contact Address
Phone Number
SECTIONS -CONSTRUCTION
F
SERVICES
Licensed Construction Supervisor/Specialty License:
License
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umber:
Company Name/Contractor Name: 'i GJ,}k (_',p fp tj,)�r.✓f 7- oyq
Address: 3711 Rock-0, awocc PO Sa• Dvemb, , co'?%q
Expiration Date: `"t ` an-i� -1Lt
Signature: Telephone: Se9"-'101-QS4
3.2 Homeowner Exemption - One & Two Family Only Section 110.135.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR 0 OJECT
Exception: Any Homeowner perforating work for which a Building Permit is required shall be exempt from the provisions of t . ' ction; 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 pare nd 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 acc 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
Signature:
SECTION 4 -WORKER'S `CO MRENSATION INSURANCE AFFIDAVIT {MGL c 152 5 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: F Yes ❑ No
SECTION 5 - DESCR1PTtON' DF PROPOSED WORK {Check all applieable)
❑ 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
(Energy report required) No. of windows -a_ 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 Ba nit 1
No of Bedrooms Unit 2 Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil ricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane e oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fu , ural gas, propane, electricity, other (specify):
❑ Air conditioning - (separ nit)
❑ None of the ab o be provided
❑ Hot W Gas Electric Fuel Oil Other
19
Item Estimated Cost ($) to be completed by permit a
1. Building aS`'(D0,.ga
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = 0 + 2 + 3 + 4) J:000r�j,
(Please Print)
i, v�+v G'tt�t/ Ai as Owner of the subject property hereby authorize t,Jd %iblM 74
to act on my behalf, in all matNr� rp4tive to work authorized by this building permit application.
of Owner
7 i 6
Date
I, GA (ky-7 1,eoT4&, , 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/Authorized Agent
Total Permit Fee: $ /9
Gross Area - New Construction total sq. ft.
Gross Area - Alterr" - ` ` '1.
Permit Issued to:
par MGL G. 0 9154
Less Application: $25. 0
Other $Amount
Date
RemainirgDalance: $
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RESJI�IfTrlT(AL e. 1, 1 ° ❑ Phased Approval (R106.3.3)
i25_00 APP11.11CA` 10TV FFF. i.0 Nt1N RF_FTfNiIARi F..G Nt�N_Ti! ANCTG i! AIli F
Revised 10/'
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
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