BP-91934Record
-&kya
"J�Owner
tU , _ I L 0 UX
Ite 0 -,w qqq
Ngme (print)
Contact Addrp-ss i`ice Phone* Number
��,K)(-
el /,51+) agy-Avu 21,WWaAle
(print) Contact Address Phone Number
-3.1 Licensed Construction Supervisor/Specialty License: License Number: 11).r46q
Company Name[Contractor Name: T-r1SLJa*i)�,- R ",LJC
Address: 5� 4, Rl Vete, 4 A - 62-7 2-3
Expiration Date:
(4ir-
Signature: Telephone:
8.2 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 N 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 helshe resides or intends to reside, on which
the:-e is, or is intended to be, a one or two family dwelling, attached or detached structures accessory 6 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:
fi 5
RIMINI ]JIM-0-0 NO T-0 RIME.
0*070W WOMAN WN
Warker'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: 0 Yes 0 No
, 0 Deck 0 Pool 0 Repairs AAlteration 0 Chimney/Fireplace 13 Woodstove/Pellet Stove
F1 New Construction* 0 Accessory Bldg, 0 Addition 0 Roofing/Siding 0 Replacement window/door
(En,vgy report required) (Shed/Garage) (Energy report required) No. of windows Doors
0 DEMOLITION (specify):
Location of debris removal (per MGL CAO Sec 54): 0 Dumpster on site 0 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 I
No o , f Bedrooms Unit 2 No. of Baths Unit 2
11 Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
0 B61er (heating) - fuel gas (natural or propane), fuel oil, elec'tricity, other (specify):
0 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
17 conditioning - (separate unit)
acne of the abow- ft%Ad
Hat
& Water: Ap Electric Fuel Oil Other
j
Item
Estimated Cost tobemyeecant
1. Building
-TD L
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
0-24-w-
LT _ NO-
'00
(Pleas ' tint}
I, as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
DA) 13L as Owner/Authorized Agent hereby declare that the statements and informeation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Ak-
SigFature of Owner/Authorized Agent Date —
Total Permit Fee: 7t;
Less Application Fee: $25.00
Other $ Amount $
Remaining Balance: $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
oc," eL, AWZ
(Y
0 PhasedApproval (R106.3.3)
525.00 APPI.i6'.a!`9'ia7v Ti ww. x.C' -wma io _wrimTra a
1.1 Property Address:,-%� 1.2 Assessors Map & Lot Number -
Contact Person: Map Lot_ --
Phone Number: �• 3- %qi
1.3 Historical District ❑ Yes ❑ No
1.4 Water Supply (MGL c40 s54): 1.5 sewage Disposal System: Year Built ?
Municipal unicipal ❑ Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commissiorn?
❑ Yes ❑ No Date:
Revised 5;//13
Lj CONSTRUCTION PLANS -QITF-: DI AKI �������� ������ l•l