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BP-925602.1 ner Record: AMN ame (print) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number 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 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 detached to use and/or farm A person who constructs more than there is, or is intended to be, a one or two family dwelling, attached or structures accessory such structures: ne home in a two-year period shall not be considered a Homeowner. If you are applying undpr this Pg re: Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial ofthe issuance of the building permit Signed Affidavit Attached ❑ Yes ❑ No f Epp t�'R�L7r-CD VY�R��'dE}eVf1�a}�t '�ticfIIte..4.. ., 'r' -.. -`u-, E7Deck ❑ Pool epairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove El1� :ew 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: 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 abor^ ❑ Hot Water: Gam Electric Fuel Oil Other i _...5. _7ft3t;.. StFAXIE?�1!1tlCTltgS, = _ _ 7Y .._ 3 Item Estimated Cost ($) to be completed by permit applicant j 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=0+2+3+4) 1LES-5 "ThArt ARb0 ° 11 STtGN d :, t_=�ont�actbra 1tes::for,buttdtn (Please Print) 1, as Owner of the subject property hereby authorize s relative to work authorized b i to act on my behalf, in all matter Y this building permit application. Signature of Owner Date �_ � ;SEC.TtOiV 7B:t�1�fE�ER/,��THO>Eii1ZI=i?_AG�ERI`i BE�LP+RA'1't€)t'd . _. - ) r X P NTb��f4NI®i ( as Owner/Authorized Agent hereby declare that the statements and information foregoing application are true and accurate, to the best of my knowledge and belief. Ll j Signed -under e pai nd ies of erjury. Agent Date of Owner/Authorized A Signature 9 Less Application Fee: $25.00 Remaining Balance: $ .� i Total Permit Fee: Other $ Amount $ r Gross Area - New Construction total sq. ft. t Gross Area - Alteration total sq. ft. Issued to: Permit I 9 )�� RIB Re )Ac4 EXI STi� W©6C[e7J 1 1