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BP-60363JUL 1 L Lulu 1. Date plan reviewed: 2. DENIED (see project review worksheet): Date: 3. HOLD Reason: Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: Inspector's Signature: GX�.CS Applicant informed of. Total Permit Fee: $ TOTAL FEE: �S Permit Issued to: e: Date: -JUL 12 2010 1 Clerk: eD d In � ri5 �vn� C�✓�- CD s"x8xs' yU k/1 -- Page 4 ❑ Approval in Part (Per 780 CMR.5111.13) $25.00 APPLICATION FEE IS NON VEE-FUNDAVSIE & lereal�T.�asAtst��t��.� 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: ® CONSTRUCTION PLANS ® SITE PLAN ® ENERGY REPORT Page 1 rSEGTION 2, ,-0AOPERTY-,O JI EE SH1P' THORIZED.AGENT, : . . Record: ,,VOwner c l� t j-to iv �T- P, e��e. �� 2 (3� ��-yi'j/-� lid SOS 99/a©./ Name (print) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number �� ..,,...SECT[OlV3. C(�[STRUCTIOIV.SERVICESr 3.1 Licensed Construction Supervisor/Specialty License : License Number: Company Name/Contractor"Name: Address: Expiration Date: Signature: Telephone: 3.2 Registered Home Improvement Contractor: Not Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? []Yes ❑ No Are you claming exemption from the requirements? ❑ Yes ❑ No If Yes, Go to Section 3.3 Company Name/Contractor Name: Registration Number (if none, state "none"): Address: = Signature: Telephone: Expiration Date: 3.3 For Residential 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 ❑ I am a Homeowner performing all the work myself. C/� `l �� w � f. ht Owne Name (print): o B signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund Date: G p `11l 6 3.4 Homeowner Exemption - One & Two Family Only FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT V:3.5 Licensing of Construction Supervisors; Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building. 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 Constructioi 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 Homeowne 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 whit 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 the one home in a two-year period shall not be considered a Homeowner If you are applying under this section sign below: Signature:�/Gll/tJ�i�-2��-� Your signature carries certain responsibilities, including but not necessarily limited to, general liability Page 2 SECfiiOi�t 4„.WORt<R'S GOMPEdSATiC?N"INSURANCE AF1DtAVIT,.(t1tlGL c'12 20 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 ....s . ,,...,. SECTION, 5;=,'DESCI2IPTfONOF Pt?OR{3SED.wORK (Check ail applicabte)„ , , ;° x -'17- ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ZOt Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding (Energy report required) (Shed/Garage) belo ❑ Addition ❑ Replacement window/door ❑ 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 ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot ater: Gas Electric Fuel Oil Other escription of proposed work: ti a.._ SECTION f:.=. ES itlitl � iED CONSTRtJC CION.CdST Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) " 5 Total =0 +2+3+4) SECTION 7A OwidER AUTHORIZATION Qom laf d`when owner's a 'ent oc.contractora ties for..6ui(ding permit} , _ ,. .. >... '` (to:be p g PP (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 x... 4.. ;SECTION 7B QWNEWAUTHORIZE AGENT.DEGLARATI(}I� as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. � �jG/a y/�d p Signa�Owner/Authorized Agent Date Page 3