BP-68732RESIDENTIAL ❑ Phased Approval (R106.3.3)
SECTION 1.-SITE INFORMATION
1.1 Property Address L e--Au A-ko n t ra jni 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map _ Lot -
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard
Rear Yard Year Built
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54): -1.5--Sewage Disposal System,- -Has application been submitted tothe-Historic Commission?
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System ❑ Yes ❑ No Date:
Revised 10/11
El CONSTRUCTION PLANS ® SITE PLAN 11 ENERGY REPt-)PT
RESIDENTIAL
SECTION 2 - PROPEI:: Y;OWNERSHIPIAUTHORIZED
AGENT ;
2.1 Owner Record:
rib . '2 bu- (2615
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Name (print)
Contact Add ess Phone Number
2.2 Authorized Agent:
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M\ok>3a 68co t
Ch 6 -� �S �� ON
Co tact A dress Phone Number
Name (print) a
SECTION 3 - CONSTRUCTION'SERVICES
3.1 Licensed Construction Supervisor/Specialty License: License Number:
Company Name/Contractor Name-
Address: ,,,�� Expiration Date:
Signature: Telephone:
3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception:
FOR HF7MEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception: Any Homeowner performing work forwhich 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:
SECTION 4 - WORKER'S COMPENSATIONINSURANCE 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 all ;applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction" ❑ Accessory Bldg. ❑ Roofing/Siding 010ther
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/doors ❑ 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 (specify):
❑ Air conditioning - separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other