BP-64803f
Vproperty Address:/3 v c� Lt 11/ � S W)RIJ K kf.) 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map C2.1" Lot
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard
Year Built
Rear Yard '
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL C40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System ❑ Yes ❑ No Date:
Revised 10/11
❑ CONSTR ON L NS SITE PLAN ❑ ENERGY REPORT
Name (print)
3.1 Licensed Construction Supery
Company Name/Contractor Name:
Address:
License:
Contact Address Phone Number
contact Address
License Number:
Expiration Date:
Phone Number
oiynarure: Telephone:
3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
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 sect' on sign below:
Signature:
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failu to provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Yes ❑ No
❑ Deck ❑ Pool
❑ New Construction"
(Energy report required)
❑ Addition
(Energy report required)
❑ Repairs ❑ Alteration
❑ Accessory Bldg.
(Shed/Garage)
❑ Replacement window/door
No. of windows Doors
❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ Roofing/Siding ❑ Other
(Specify below)
❑ Demolition
(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
d 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
11 Hot Water. Gas Electric Fuel Oil Other
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC
5. Total =0+2+3+
Estimated Cost ($) to be
(Please Print)
I, as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
Date
nt
I,�IIQ'TL� as Owner/Authorized Agent hereby declare that the statements and information
;igned
th oregoing application are'fue and accurate, to the best of my knowledge and belief.
under the paips and penalties of oeriury
Agent
1- �-
Total Permit Fee: $
Gross Area - New Construction total sq. ft. ,
Gross Area - Alteration total sq. ft.
Permit Issued to: VM 4 lam" ('.
Less Application Fee: $2
Other $ Amount $
STZ)U�P_
Remaining Balance: $a—
a� �LAr�ge