BP-79206RESIDENTIAL ❑ Phased Approval (R106.3,3)
$25.00 AIPPLICATION FEE IS NON BE -FUNDABLE A NON -TRANSFERABLE E
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1.1 Property Address: yU`-?r��i �,`L 1.2 Assessors Map & Lot Number:
Contact Person: _ :3Q--W �- LAs r Map _ Lot -
Phone Number: Lit) 1-1
1.3 Historical District ❑ Yes *MO
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
Year Built
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5 /
❑ CONSTRUCTION PLANS 0 SITE PLAN 0 ENERGY REPORT
RESIDENTIAL
= ` SECTION -r `PROPEttT -,! ERSHIPIAU3"-HQRI
2.1 Owner Record: - O O
Name (punt) Contact Address Phone Number
2.2 Authorizeedd Agent:.
Name (print) Contact Address Phone Number 7
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3.1 Licensed Construction Supervisor/Specialty License: l License Number: (y
Company Name/Contractor Name: j4ienr%eAV1
�,�3 �' �
Address: �� 1
Expiration Date:
�� 1-7
Signature:
--��--' Telephone: _ _ (P$
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3.2 Homeowner Exemption - One & Two Family Only Section 110.R5:1.3.1 Exception:
S WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
FOR HOMEOW�fo
Exception: Any Homeowner performing woich a Building Permit is require • ILha-exempt from the provisions of this section; provides that if a Homeowner
engages a persons) for hire to do such work,uch eowner as supervisor.
For the purposes of this section only, a "Homeowner" is s 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 famil ing, attached or ached structures accessory to such use and/or farm structures. A person who constructs than
more
one home in a two-year period shall not onsidered a Homeowner.
If you are applying under this section sign below: '
Signature:
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: -�Iq'Yes ❑ No
t*. SE�TIaIV 5,_C?ESI~RtPTfON'33F�PFtQPt���Q-;1it�ORK [Ghecl€ali°,�ntalrr�hfQ� _,. f :_
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. _❑ Addition ❑ Roofing/Siding JR-Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows j Doors_
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site
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 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): _
O 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
❑ Dumpster On Street
Other