BP-82125RESIDENTIAL
Item Estimated Cost ($} to be completed by permit applicant
SCTI{fl12 "PPf3PE1iYO11iN�I11RU1CHORIZE� AsNT .. ,... ....{
1 Building
;.. . ....
2. Electrical
2 Owner Recor : r r 3. Plumbing
,1 4. Mechanical (HVAC)
Contact Address Phone Number i9
5. Total = {1 + 2 + 3 + 4) Il( .
Name rent ERAu>izT
(print)
CTf01� iA OWN
`:�O%` tilatlCllii �1`�l�t)
gho e A elt:_. n g
Mann-4 (print)
ontact Address Phone Number I /�� l ��� as Owner of the subject property hereby authorize
777r7777777777. to act =my behalf, in al(matters relative to work authorized by this building permit application.
Ct)HRt)C'fi1UT1R�IICES _ =
SEGT1flN 3 ST _
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License Numbe ' Date
3.1 Licensed Construction Supervis r/Speci Ity 'censer Signature o Own r
___ vt.-777
Company Name/Contractor Name.
j EC)IRTlpht ,, T> ,
Expiration Date:
SE�TEtiN 7B�-OWf�ERIAUT�4�iiRl,���;AfilENti} ,.
Address: +
T.G t state an information
Signature
as Owner/Authorized Agent hereby declare that the merits din n
3 on the fore oing application are true and accurate, to the best of my knowledge and belief.
3.2 Homeowner Ex ption - One & Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Signed unde pains and p ies of perjury.
Exception: An Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner
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engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor. Date
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 Signatu e of weer/Authorized Agent
For the purposes of this section y,
structures accessory to such use and/or farm structures. A person who constructs more than
family dwelling, or detached rY -
there is, or is intended to be, a one or two y 9
x
one home in a two-year period shall not be considered a Homeowner:
If you are applying under this section sign below:
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $Amount $
Signature:
i�t Ff`(f}�@�/1T V.VIGL
4:iff,z171CQfFI;ixk7lUIE�1i4C#QNJ . + Gross Area - New Construction total sq. ft.
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
Gross Area Alteration total sq. ft.
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑Yes ❑ No Permit issued to:
>, EE3;;CiRK
la
_.
Se�Tj[ii ... i]ESGRIPtI I t? ,PRIQP S
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace oodstove/' ellet St e
(Energy report requireu) tJncurvaiay�—••-•ai
❑ DEMOLITION (specify):
Location of debris removal (per MGL CAD Sec 54):. ❑ Dumpster on site ❑ Dumpster On Street
Facility Name: Location:
*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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
0 Hat Water:. Gas
Electric Fuel Oil Other
1 �--,�
c
I
S 1
® Phased Approval ( R106.3.3
$25.00 PLICATI®N FEE IS NON BE -FUNDABLE & NON -TRANSFERABLE
1.1 Property Address: 11 n 1
Contact Person: ` r� �a,
Phone Number. Ol5 }9qrj
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
1.2 Assessors Map & Lot Number:
Map —�--1 Lot
1.3 Historical District ❑ Yes ❑ No
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
0 Yes 0 No Date:
0 CONSTRUCTION PLANS 1:1 SITE PLAN DENERGY REPO, IT