BP-81634RESIDENTIAL ❑ Phased Approval (R906.3.3)
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Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of work being perfonned.
1.1 Property Address: 11.jo &= `V/S 1.2 Assessors Map &Lot Number:
Contact Person: mowi�ld'-�—� Map�� Ate— Lot= -
Phone Number:
.3 Historical District ❑ Yes No
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
Year Built
El Municipal El Municipal ❑ AI enn o per side of buildintg
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5 /13
❑ CONSTRUCTION PLANS El SITE PLAN ® ENERGY REPORT
RESIDENTIAL
W SECTION-6 "MATED COINSTRUCI 1t3N COSfi
2.1 Owner Record:
CIS
Name (print) Contact Address
Phone Number
2.2 Auth ' e ent:
Name (grin Contact Address
Phone Number
3.1 Licensed ConStruCtba-Survisor/Specialty License: License Number:
CoAla Name: .,�//g
Add5� Expiration Dat
SigTelephone:
3.2 e & T FamilyOnly Section 110.R5.1.3.1 Exception:
WNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Excrming 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 its intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/orfarm structures: A person who constructs more than
one home h a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
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
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facility Name: 17Ve Location: ,j4�� /0
*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
❑ Hot Water: Gas Electric Fuel Oil
Other
(Please Print)
I, as Owner of the subject property hereby authorize
to act on my behal all matter I e to work auth Ped by this building pemlit application. T
Signature of efwner _ `" _ ` Date
SECT[ON 7g - WNEFtI/�UTHORIZED A0EN� QEt ,RATION.,,:
I,4k 64 6 as Owner/Authorized Agent hereby declare that the statements and infoirmation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under�inpenalties of perjury.
Signature%91(r/Au-thorized Agen
7 3 Less Application Fee: $25.00
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total
xxel"total sq. ft.
Permit Issued to: AI / /l+'
I
1131 �--A
Remaining Balance: $}�