BP-46430SECTION 8
1. Date plan reviewed:
2. DENIED (see project review worksheet):
3. HOLD
Reason:
4. HOLD subject to Zoning Board of Appeals action:
Comments:
Inspector's Signature:
—SECTION SEC ON 9-APPLICANT NOTIEIt
Applicant informed of above: Date: Time:
Comments:
SECTION 10 OFFICE/INSP CTOR'
Less Application Fee: $3'O>T
Total Permit Fee: $ 30
Other $ Amount $
TOTAL FEE: 3 G , d d Gross Area - New Construction total sq. ft.
/;ss Area -Alteration total sq.ft.Permit Issued to: t _ �1.7
Date:
Date:
Date:
Remaining Balance: $
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
@2S an AhPi.i(`Awilax Fi2F. iC 1W"V RF_TiiTlVilAi 11v R N(�N-TRAN.CFFiRAiti.F.
SECTION 1 - SITE INFORMATION
1.1 Property Address: /, lls5t,4'-S "wa-S J0,
1.2 Assessors Map & Lot Number:
Nearest Cross Street: 4/0014;GOG'K RZ •
Map Lot -
Subdivision Name:
1.3 Historical District 12 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:
JO Municipal ❑ Private Well
❑ Municipal 19 On Site Disposal System
01
❑ CONSTRUCTION PLANS ❑SITE PLAN ❑ENERGY REPORT
f
,-RESIDENTIAL
�. ... SECTION 2 -`PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Owner Record:
^1f, t MoNZtE�f V
/%O -7 12VSsEus 3*4rW 3/9
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
�'- SECTION 3 =`CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: e��% �— IWIV
Not Applicable ❑
Licensed Construction Supervisor:
License Number:
Address: �17G�® �(/�
Expiration Pate -
Signature: Telephone:
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? aryes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name: `9n/7VOWY i✓Af/Te_ GD,v$T •� ,z/✓C,
Registration Number (if none, state "none'):
Address: 7 -7-L�N00�
Signature: 1el Telephone:-3-40r /92'36�Z
Expiration Date:
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING 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 `
❑ 1 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
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
SECTION 5-DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. 940ofing/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 prop sed work:
6
I Item I Estimated Cost M to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4) 1
(Please Print) _L /� y
1, 5 � +7 I 1 4 " mot, as Owner of the subject property hereby authorize /« a,*rT Z�^i1��'�/
to act on my behalf, in I matters relative to work authorized by this building permit application.
8�.. k
Signature of Own Date
SECTION 7B - OWNERIAUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true andAccurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
of Owner/Authorized
Date