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BP-92467-19RESIDENTIAL _�E�TIC4h! 8= _- —� Item SECTION 2 f'RF3PERTY_C111Vi'tl=RSHlP/AUTFfO. FZ(ZED AGEtN.T - 2.1 Owner Record: 36 4Z_1,, Kt1--s 9/b 0 K S'.1%r�ay+t, 11At)zzq� 4qy,— Name tpnnt) Contact Address Phone Number 2.2 Authorized 'Agent: / /ZG3S�rvY5rC- 1i�t i� 7 r ;fh-f'r~lr( ��"� t 1-2r—�� ' I Name (print) Contact Address Phone Number -_ _, _SEGTIQN-3 ,CONSTRUGTiON:SEE��lICES � � _ 3.1 Licensed Construction Supervisor/Specialty License: /3' License Number: Q p / Company Name/Contractor Name: Piii e5) 1 [ rind cu ' / �7 `{355 Address: Q PSe,- � `f \n D �h, "fie �G{ �I / f iC- -lg- Expiration Date.. �? ,� 0_ C SL — �% 3 -2-v \. 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 persons) 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: � {lV -- _ - � �BK�� O�►dI=ENSAT�¢[�f #�FSIIi�Ai�€�E,�iFFIE}AF/tT (A1tGi.� c_'fS2.� 25j _ - -- Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure tq provide,this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: t Yes ❑ No SEGtO6t 5 `DESCQ[PTtt3tV OFPRE?POSEi li1FORk (Ghec�affappitcaEte - } ❑- Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ I\1e6 Construction` ❑ Accessory'Bidg. ❑Addition ❑ Roofing/Siding C5`Replacement window/door „(Energy report required) (Shed/ Garage 1 (Energy report required) Na. of windows Doors T� G ST it1CTiONC08T. Estimated Cost (,$) to be comp) nit applicant _ 1. Building - S $ 44 2. Electrical 3. Plumbing 4. Mechanical (H`•IAC) 5. Total =(1+2+3+4) SEGTi0�1 01JfuER�ltlTHOR(ZATtit he ;`owner's a ent`or cor& _ (ti© be rtotrtpletecf n- g _ racfor-applies far [auitdir�g ptmit . (Please Print.) I, as Owner of the subject property hereby authorize to act on m behalf. in all matters relative to work authorized b� this building permit application. y ( I 9 P PF Signature of Owner Date SECTION TS 0W4EFt/AUTH.bi0I=b-AGtNT DECLARATION I, ili�� n c SQ/1 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 d penalties of perjury. Signature of Ow o iz Date =.-0 F[C tV - SECI [ON 8F , E/1 SPEGTOR S NOT Less Application Fee: i$25.00 Remaining Balance: a Total Permit Fee: $ Z��"' Other Amount Gross Area - New/ Construction total sq. It Gross Area Alteration total sq. ft. f 4 Permit Issued to: L DEMOLITION (specify). - Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dum ster On Street E T WOO ��...��ESGRiO Facility Name: Location: - m 4?a<,OT�ree,.V �✓ �aG w� 'If new construction, please complete the following: Single Family: No. of Bedrooms No. of Baths _ a 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 orpropane), fuel oil, electricity, other (specify): D NN/AC (combined unit) - primary fuel, natural gas, propane electricity, other (specify*': ❑ Air conditioning - (separate ueit) ❑ None of the abor- OwiftkAd - 0 Hot `Hater•. , Ga� _ - �- - _ Electric Fuel Oil Other j 1.1 Property Address: &14rs gook <—�06 Contact Person: 7�4p�,711 "s-0/1 Phone Number: Z k- G Ap o 1.3 Historical District ❑ Yes ❑ No Year Built 1.4 water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal ❑ ,Altering more than 25% per side of building ❑ Private well ❑ On Site Disposal System Has application been submitted to the Historic Commission? 48 ❑ Yes ❑ No Date: Revise 5 `1:3 �rL%_ j A ML i A 33 �aa�raaa�a a4�.aasara i%YLJ j