BP-9564-99i
800 MECHANICAI-S & PRMARY FUEL
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
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goo SPRINKLERS - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
Required, --plans provided, plans not provided, why?
Not required, not to be installed, Why?
1000 REQUIRED OFF-STREET PARKNG for ZONING & Architectural Access
NOT APPLICABLE
= Parking Plan submitted To Building Department Z Planning Board Date submitted
Number of spaces - indoors outside total provided
Handicap spaces aces required yes _no. If yes, how many as a pirt of the total required number.
Is Route 6 (State Road) Entrance permit required? yes no If yes has it been issued yes no �.
Submit copy of application and/or permit as soon as available.
1100 IDENTIFICATION (print or type except as noted)
Current owner - name �A �'S A,I' it 'f C Gy f S da/1
address
phone #
If corporation, officer in charge i
Architect/Engineer - for overall design
Company name <!p fin SC�ha" tiZ�t�
Address A JmA f wt at °
Phone number
Certified by State of Massachusetts as �i G
Certification number'
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
ArchitectMigmeer - project supervision and reports
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
General Contractor (if Homeowner, state homeowner here then complete section 1300)
Company name �dil ►''
Address Y�I Q. io�,l s�✓rl�iewi4�`f
Phone number a� 1
Construction Supervisors license number C- 2
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NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
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1200 FOR RESIDENTIAL REMODEL WORK ONLY
Improvement Contractor subject to 780CMR - 6) ? YeS� No If no o to next section!
Are you a Home Impr J ( — _ g
Are you claiming exemption from the requirement? Yes _No _If yes, submit the required affidavit!
Ren_,)del contractor name lease Tint
Address
�I
Registration number (if none state "none") T
Phone number 92=
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE
GUARANTEE FUND! QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration
One Ashburton Place -`Room 1301
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Boston, MA 02108
(617) 727-8598
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Owners name (Print)
Signature
Date�I
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1300 OWNER SIGN - OFF
I, the undersigned, am the owner of record or authorized lessee (provide documentation) and I have reviewed
the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this
application is true and correct and that the permit requested be issued.
Further I understand that the permit will expire in six months,from the date of issue, if no work is begun or
six months after the last inspection if work has begun andthat the permit may be extended for six months if no work is
anticipated if I request such an extension in writing. I understand that the permit may be extended only three times by
written request. I understand that once the permit expires a new application may be required, including fees and current
other requirements (including Zoning).
_.:.Name od —V4-t j_,�
Signature
The above signature is my voluntary act and is signed under the pains and penalties of perjury.
Date
Who is authorized to pickup the permit at the Building' Department? !please orintl
Address Phone
1400 HOMEOWNER EXEMPTION ONE & TWO FAMILY ONLY
FOR HOME OWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT.
109-1.1 Licensing of Constriction Seperoiisom: Except for those structures governed by Construction Control
in Section 127.0, effective July 1, 1982, no individual shall be engaged in directly supervising persons engaged in
construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings or
structures, unless he or sheds licensed in accords-ce with the rules and regulations promulgated by the BBRS entitled
Rules and Regulations for Licensing Constriction Supervisors.
Exception: Any Home Owner performing work for which a Building Permit is required shall be exempt from
the provisions of this section; provides that if a Home Owner engages a person(s) for hire to do such work ,that such
Home Owner shall act as supervisor.
For the purposes of this section only, a "Home Owner" 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
two-year period shall not be considered a Home Owner.,
If you are applying under this section sign below:
Signature
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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licensed Construction Supervisor, whether or not they have taken the permit are responsibleNOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any
for code compliance (see 2.15.2 of section 5)
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1500 COST
Cost of Improvement
Items to be installed but not included in the above cost: ElectricalSO
Plumbing _
HVAC
Other
TOTAL
tAtteratio® of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required.
= Demolition - describe structure
Number of dwelling units Number of bedrooms A separate Reface Disposal
Declaration required.
Moving - (Provide copy of D.P.W. moving license)' Type of structure
from where (plat/lot or address)
to where (plat/lot or address)
Number of dwelling units Number of bedrooms per dwelling unit'
- Re-r frog - (for existing only, is included in new construction)
Number of square feet Number of layers already existing
Number of layers when complete
A separate disposal declaration REQUIRED
Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be
enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling will be
considered as an Alteration, otherwise will be included in new construction. (see Code section 3401.10 for
residential and Articl • 8 ft- - commercial) _
Temporary structure -dd includeswhenallowed, trailers, tents and the like and only for limited periods of time.
Describe l�/24.t,_ . `�0 s,rW1 1e_.r Zvi !t ► i�'Yt a,{p °'v 0yoy S
500 CONSTRUCTION PLANS
None submitted.. Why?
2-Submitted, usually three sets required. Four sets for food service uses. Number of sets submitted'
600 SITE PLAN
t] Not required, why?
Submitted When? = Previously, date ❑ With this application
70� IZ'IFES
Water supply - required_ yes _ no, public ? _ yes _ no, on site well? _yes no,
existing? yes no
If required and not existing have necessary permits been issued? no — yes, date
(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, when
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required ,_ yes _ no, public sewer _ yes no
private septic - on -sits _ yes _ no. Submit copy of permit as soon as available.
_ I,
W'oodstove - ged f.,W' The following section for official use only.
wu iv require utspectidn prioi ,to installation), ,new (provide manufacturers
instructions). Location(s) (list) INSPECTORS' REVIEW
!i Fireplace(s) - (includes flue) List location(s) Date plan reviewed
- _ Game Court -describe (include overall dimensions) 30 days to review period expires-
_Tent, `Trailer (Mobile Home) or Other -describe
OK to issue date
300 COMI1ffiLCIAL -PROPOSED PROJECTJUSE INCLUDING THREE FAb1ILY OR MORE AND EXEIt4PT USES i OK to issue subject to requested submittals (see project review worksheet) date
THIS SECTION NOT APPLICABLE
DEp NIED see ro ect review worksheet date
J
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED) (See the
HOLD reason date y
Code)
_ HOLD Subject to Zoning Board of Appeals action
= Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
Comments
Business- office, assembly with less than 50 occupants - indicate Medical or other professional (see Code
Inspectors signature Date
Section 303.0)
Applicant informed of above- Date 4e) staff (fax, phone, in person)
_ Educational - structure for training including child day care for those over 2 years 9 months (see Code Section
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= Over six months since approved for issue - DEEMED abandoned'
Factory Industrial - (see Code Section 305.0) Advise applicant. Hold 90 days for return then dispose if not picked up.
= High Hazard - (see Code Section 306.0)
Inspector Date
= Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
Advised applicant Date Time staff (by phone, fax or in person)
Mercantile - retail stores (see Code 308.0)
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Residential - three or more family,hotel (see Code Section 309.0) OFFICEUNSPECTORS NOTES
_ Storage includes garages (see Code Section 309.0) TOTAL FEE �00
' =Utility &Miscellaneous Structures -includes tents and agricultural structures (see Code Section 311.0)
Gross area - new construction Total Sq. Ft.
i�
New tenant for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35)
alteration Total Sq. Ft.
= Tent or Trailer - temporary purpose? Permit is issued to
_ Other
Describe the proposal briefly, INCLUDE -•amber of dwelling units and bedrooms or occupant load as applicable,
also existing condition
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
x
= New Construction and/or Addition - total gross square feet
1; (For commercial only total gross cubic feet) - indicate
It will be considered new construction if there an increase in square footage in addition' to any
alterationts).
If project is an addition to existing structure Total gross square feet of existing
FOR COMIKERCIAL ONLY
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu.ft.) Yes No. (If ves
see Code section 127.0). Designer to submit Code Synopsis.
Will this project require Peer review lover 400.000 cu.ft.) Yes No (see Code Appendix I)
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1600 TO THE APPLICANT AND APPROVAL
Date of Application submission ] /
11)0
Plat Lot � Street Aquifer Zone
Owner
Owner mail address
Owner phone # f /U
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OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictional permits or approval for your
proposed project. CONTACT THEM FOR REOLmt1M S0 IS.SIONS.
�AX COLLECTOR'— Approved HOLD By
Date
❑ Board of Appeals Approved By Date
❑ Conservation Commission ` Approved By Date
❑ D.P.W. Water — Approved By , ❑ D.P.W. Sewer Approved By Date
Cl D.P.W. Cross Connection Approved By Date
❑ Treasurer (Bond) ❑ Approved By Date
D D.P.W. Engineering_ Approved By Date
7 Board of Health (well) = Approved By
Date
C] Board of Health (septic) — Approved By Date
❑ Board of Health (food service) _ Approved By Date
❑ Planning Board (parking) - Approved By Date
® F RE DISTRICT (I - II III) Approved By Date
BUILDING DEPARTMENT APPROVAL:
❑ ZONING
❑ BUILDING INSPECTOR/BUILDING COMMIISSIONER
CONTROL CONSTRUCTION AFFIDAVIT
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PROJECT SUMMARY:
new construction/ alteration/demo sewage disposal - public; private
[A.lter:add interior walls] [add rooms] [add footprint] water supply - publiciprivate well
[pool] [gar geishedldeck] [game court] [food service]
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Describe 6(s( %i -
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To the various departments:
This notice has been forwarded to you for your information and any appropriate action. Should you have anv
questions please advise. If any reason to withhold the requested permit is found, please advise. Your assistance and
cooperation is appreciated.
The BuiidinE Department Date sent for review L / Bv = 753
Iastroedom
The applicant shall complete this application to the best of their ability prior to submission, leaving no item ®answered. 'The
Department staff will be available during regular business hours to assist as necessary. N/A should be inserted for those sections
which do not apply. A properly completed application will help avoid unnecessary delays. N I ii� fees a®t
(for office use only) TION ONLY
Total Cost $ Received By Date Rec'd `?
Less Application Fee $
Total Permit Fee Permit # Lswed Date
i'
100 LOCATION OF PROJECT TOTAL LAND AREA SQUARE FEET
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CURRENT ACCESSORS' PLAT I LOT ZONING DISTRICT
OTHER ZONING OVERLAY DISTRICTS€.�+ C ,-if applicable
NUMBER & STREET f o yz Z I( Ir
.Q V
NEAREST CROSS STREET s-iL� C' i�`1 s
SUBDIVISION NAME & LOT #
or BUSINESS NAME
PREVIOUS TENANT / OWNER
200 RESIDENTIAL = PROPOSED PROJECT - one & two family residence only
- TH S SECTION NOT APPLICABLE
LAI
Single family - number bedrooms number baths
Two family - number bedrooms unit 1 number baths unit i
number bedrooms unit 2 number baths unit 2
= Accessory apartment Total gross sq. ft.
_ Accessory structure:
Garage -`detached - attached to dwelling, dimensions L W
= Carport - detached - attached to dwelling, dimensions L W
= Shed - dimensions L ° W
= Deck -dimensions L W
_ Gazebo dimensions L W
Swimming pool above ground in -ground Size
_ Chimney - number of flues ,