BP-91511RESIDENTIAL
SEU i02 'Rff`PERTY �WNitrFiEHfPfi!4[jTHORIECtENT,
2.1 Owner Record:
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Name (print)
Contact Address
Phone Number
2.2 Authorized Agent, `
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Name (print)
Contact Address
Phone Number
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3.1 Licensed Construction Supervisor/Specialty License: License Number: C5 6 5 C 3
Company Name/Contractor Name: y?5 d ;t 1133 "15'
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Address: W D VS ell . � � k A4
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Expiration Date:
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Signature: 5 Telephone:56 it It -•Sr
3.2 HomeowrOr Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
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 tie/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 his)section sign below:
milyingder
Signature:
r «�E,OTION �- , Yt►�gRK�r �Q11d�?ENSAt�{�I�tif�lSUi�Ai�!'OE i�F�Jt}�l�t/1��(A1��L.,c �52,§ ��� .. _.;� . 4_ , .. � F .. �_� .._
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
SEGTIt3IJ`5 D�SGRtf�� [.f)t QFP(�QPSEQ Yli'4I2,(L`lec[ aftpitcabRom `e, .
❑ Deck ❑ Pool ( Repairs J�Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition Roofing/Siding q Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows o Doors
❑ DEMOLITION (specify): MOVIr P1451-RVr A. -el LA+� �
Location of debris removal (per MGL C.40 Sec 54): �Dumpster on site ❑ Dumpster OH Street
Facility Name: 8 C Location:
I
*If new construction, please complete the following: `
Single Family: No, of Bedrooms L� J
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):
-
,VHVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): eLe c+r P
❑ Air conditioning - (separate unit)
❑ None of the abos ivi d
(Hot Water: Ga_ Electric Fuel Oil Other
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing 33- 490
4. Mechanical (HVAC) J i Gti
5, Total _0+2+3+4) 000
:_ `} SECTION �A OII�T�IEF��I�TF[C�ti%�Tltil�i -
{to be-�orrtpteted �hen,owfter`s`agenf or cottfac>�"oirspplLes'�or tiiild�ng permtt� .
(Please Print)
l ^ (' d tQDO as Owner of the subject property hereby authorize (
to ton �ybehalf, .a I matters relative to work authorized by this building permit application.CIL�t-�
Sig at e of Ow r Date
j,, SEGTIOh) 7t3 OER/AUTktORIZEt� AGE'IVT �EGt�st�;4TION
i�i lyA 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 under the pLndltiesof perjury.
Sign e of Owner/Authorized Agent Date
SC 1 [Qt�t $ tSFFiGEit[SPIeC iQR�S NOTES `
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $ � _"""
Other $ Amount $
Gross Area - New Construction total sq. ft. _
Gross Area - Alteration total sq. ft.:_
, Permit Issued to: c e
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RESIDENTIAL
$25.00 APPLICA
PhasedApprova( (Rl(,6,3.3)
FEE IS NON BE-FUNBABLE & NON-TBANSFEBABLE
Contact Person; -)tkfA-) [,Ileur/Vq ✓q
i CONSTRUCTION PLANS
Revised 5 /13
ENERGY REPORT Ai5