BP-86287-07RESIDENTIAL
-•:_• _,.. `= - -. ___: SECTION 2=:_:RRCIF�RTY OINNERSHIF/AUTHORIZED AGENT ,.- - _
2.1 Owner Record. t ,
CRA15 0 Ale-) L f ;� K�eiRst��c.Lt° � Sig
Name (print) Contact Address Phone Number
2.2 A,y�thori ed gent
Name (print) Contact Address Phone Number
- - a_ ,SEG?IdN 3`�,C�DN�TRUCTION SfERVI�ES _ -
3.1 Licensed Construction Supervisor/Specialty License: License Number: D 115,g4Q
Company Name/Contractor Name:
5efi me, J+o_ �IY1 (,CC ,� t,53 S1_1 1
Address: ! ACO RI k tl" AD Expiration Date:
Signature: Telephone:L506 5t f -107
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 section sign below:
Signature:
S�GTIDN. 4.4V�RK£R'S COII�PEIV,S'ATIQN iNSUFtAl�I�E i�FFIDAVtT,-(N11GL �:152 § .�51 _ _ ---
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to�rovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Q'Yes ❑ No
'SE71N 5 = DESCRt.t10N OF.P,RCPUSEDaIVORK;(Chebk all applica6l}
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace. ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition Q'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): El Dumpster on site ❑ Dumpster On Street
Facility Name: P(C � �54`0e Location: �6C e5 ��
�
*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- 9-h.. v d
0 Hot Water: G*_ _ Electric Fuel Oil Other
SECTION = ESTIIVIATED'CONSTRUGTIi]N,GOST7777Z- -
_-
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0 +2+3+4) 00
(Please Print) f,15
I, CCll as Owner of the subject property hereby authorize
to act on my b Palf, in all matte elative to work authorized by this building permit application.
Sign re of Owner Date
I, C"0 L4 S�rssOwner/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 (ties of perjury.
Signature of Owner/Authorized Agent Date
LS Less Application Fee
Total Permit Fee: $ _
Other $ Amount $
Gross Area - New Construction total sq. ft. _
Gross Area - Alter,
Permit Issued to:
Remaining
RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -Fr ;SABLE & N0N.Tn&1®T,Cwrn,% r w
1.1 Property Address: IA-4 4414
Contact Person: -Pt- P, A . i ` u L t C✓
Phone Number: S Q S <�6)
1.4 Water Supply (MGL c40 s54): 1.5 S� e}�'age Disposal System:
C�Municipal C municipal
❑ Private Well ❑ On Site Disposal System
1.2 Assessors Aaot Numb7L--
MapLot
1.3 Historical District ❑ Yes ar o
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
0 Yes 11 No Date:
CONSTRUCTION PLANS SITE PLAN 0 ENERGY REPORT 86)-�7