BP-93747-19ES' ENT'
SEGi 1�11 Pl�F3PER [ Y OWIVER§114-0
[ITHOKIZED -
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2.1 Owner Record:
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Name (print)
Contact Address Phone Number
leRes--rt/Drf'
2.2 Authorized Agent:
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Name (print)
Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License:
License Number: Q —p
Company Name./Contractor Name: � Pin �/1 � ,� � end � S � e ,5— 17� `� S
Address: Q eSe,, : f cf -�; -fie [C( &-U,5 / %
Expiration Date: H Ic" —19-2 0
Signature: Telephone:
3.2 Homeowner Exemption - One & Two Family Only Section I I O.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 shalt 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 lard 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 whopgstrupts more than
one home in a tiro -year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
EOTlO WOF i{ER` OAK"FFlDAY1T'(MC�i�c
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to,pcvide this
kYeS No
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑
_ S�GT[OEi � DESGRIPT[t3fd Q�P�OPC3�LEI_It�aRtff �Gheck ail;app{ica6{e) _. r _- _ = _ -
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Wood stove/Pei let Stove
❑ New Construction* > ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ff 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 fi
No of Bedrooms Unit 2 No, of Baths Unit -
❑ 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):
0 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning -(separate unit)
❑ None of the above-- ,.. wed
Hot Water: Ga _ — - Electric Fuel Oil Other
EGTiON 6Tti[AGEd300STffUGTiOf,GST
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0+2+3+4)
S GTIOf� A OVtfTFEO[ (2:ATi6,N
owner`s a ent"ar codracfor a _ices for bu[ldin a"rmit
:fro be-�amp[efec! when_= - ,. ,.:.. 5 _ _. -._ _ .. -f�R _ _ _ � i�... ) -
(Please Print)
1 --� as Owner of the subject property hereby authorize i ►Qn �i�!►f S
to act on my Yehalf, in all matters relative to work authorized by this building permit application.
-- /firy- w r" P f
Signature of Owner Date
BECTi( h� 7E 0WNER/AUTl t3 lZE ,A4�ENT DEQLAi T i�t - -
d rf, 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 pe alties of perjury. -
Signature of Ovvner/Au gent Date
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:.. -
e
v� Gr" w/
RESIDENTIAL ❑ Phased Approval (R106.3,311
1.1 Property Address: 3a 331ac6.1r_3 �l�t, �" 1.2 Assessors Map & Lot Number:
Contact Person: " S10n tvlap Lot
Phone Number: '-i®(-'1 L R- ? p o
1.3 Historical District ❑ Yes ❑ No
1 A VVater Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
0
❑ Yes ❑ No Date:
Revised 5 /1
CONSTRUCTION SITE PLAN
LJ R 1