BP-55471"SECTION 8 - INSPECTOR'S REVI
1. Date plan reviewed:
2. DENIED (see project review worksheet):
3. HOLD
Reason:
4. HOLD subject to Zoning Board of Appeals action:
1 Comments:
I Permit Issue
MENTS
Date:
Date:
Date:
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RESIDENTIAL ❑Approval in Part (Per 780 CMR.5111.13)
$25.00 APPLICATION FEE IS NON RE-FUNI)ARLE & NON-TIRANSFERARLE
SECTION 1 -SITE INFORMATION
1.1 Property Address:
.2 Assessors Map & Lot Number:
Map_ Lot
Lot Area (sf.) Frontage
_�-
Required Provided
Front Yard
1.3 Historical District KYes ❑ No
Side Yard
Has application been submitted to the Historic Commission
Rear Yard
V-Yes ❑ No Date:
ter Supply (MGL c40 s54):
1.5 ewage Disposal System:
/02Municipal Private Well
❑ Municipal t2,On Site Disposal System
CONSTRUCTION PLANS
❑ SITE PLAN
❑ ENERGY REPORT
SECTION 2 - PROPERTY OWNEkSHIP/AUTHORIZED
AGENT
.1 Owner Record:
I
A I/0
q Z- 5t5e S
Name (print)
Cootact Address / 6 , Lhonq u � er
1
2.2 ed Agent: �--� �rs�ti—a �- (i O5J/4V
Name (print)
Contact Address Phone Number
SECTION 3_-CONSTRUCTION
SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor. `—
License Number: ZZ.3 C�
Address:
piration Date:
17— A
Signature: Telephone: l) �� j -
3.2 Regis red Home Improvement Contractor:
I
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)11-1
Yes ❑ 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: —
istration Number (if none, state "none"):
Address: -A
S
Signature: Telephone:
�45-- �
Expiration Date: ZZ
3.3 For Resid ntial 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):
V
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
5108.3.5 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 fans 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
v
SECTION 4 -WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 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: Yes ❑ No
`SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check gill applicable).
❑ Deck ❑ Pool -Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction' ❑ Accessory Bldg. KRoofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition V4 Replacement windoyflcioor Demolition
(Energy report required) No. of windows Z5 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 afral ec p ane) 'oil electricity, other (specify):
-Boiler (heating
heatin I tural or ane uel ' , electricity, other (specify):
❑ HVAC (combined unit) - prima 4u , 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 proposed work:
"PC) nye C
SECTION 6 - ESTIMATED CONSTRUCTION COSTRAl
Item
Estimated Cost ($) to be completed by permit bplicant -
1. Building
C�
2. Electrical
3. Plumbingon
4. Mechanical (HVAC)
5. Total = 0 + 2 + 3 + 4)
SECTION 7A -OWNER AUTHt-1141ZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please P int) L
��rvi�TS
I, Own of the subject property hereby�u orize
to act Qn my be If, in all matters relative t vork, a tt o e by this building permit application.
2- --0
Signatur of Owne Date
SECTION 713 -OWNER/AUTHORIZED,AGENT-DECLARATION .`<- .. , . .
as Owner/A�-ereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Sign; der the pains and penaltiel of perju -
Signat re of Owner/Aut 5iied A e Da
Jr