Loading...
BP-44694>SfCTION 10'-.OFFIC INSP R'S NOTES Less Application Fe&425..99-• Remaining Balance: $ Total Permit Fee: $ �.��/ Other $ Amount $ ZED TOTAL FEE: Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. � � D� v Permit Issued to: —/ [�f%% xg/ 11.0--A J ❑ SPECIAL PERMIT (Per 780 CMR 111.13) IZJ.VV AYYL1lA'1'1Vlr' 1AILIE 111NV1r ISE-FUNDABLE A 1VV1V=1'1{E1NS'FEBABILE THE FOLLOWING AGENCIES bt(l LIJ ! IF Appeals ` Health Commission Affidavit Card Sent?-'' ent Cut Off Follow up* ❑ Fire ❑Gas ❑Planning ❑Sewer Card ❑Water Card , , ❑Zoning ❑ Other Chief r= Cut Off Board ' =`Cut Off •: Cut Off '' *REQUIRESINSPECTOR'S REVIEW BEFORE THE ISSUANCE OF APERMIT. " - - DEPA TMENTAL APPROVAL ' Zoning Review: Signature: 6✓:�a�-' Date: Energy Report: Signature: Date: Signature: Date: J;Fire_Lhief: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: Brief description of work being performed: �- SECTION 9 - SITE INFORMATION TT II 1 Property Address: % &1+zTk 10 d 17 1.2 Assessors Map & Lot Number: Nearest Cross Street: YL a /LC 4— Map �� Lot S 1_ Subdivision Name: FT/ 39/,OGC- �06 S 1.3 Historical District ❑ Yes ❑ No Total Land Area Sq. Feet: Has application been submitted to thie Historic Commission? ❑ Yes ❑ No Date:: 1.4 W er Supply (MGL c40 s54): Municipal ❑ Private Well 1.5 Sewage Disposal System: ❑ Municipal %H On Site Disposal System ❑ CONSTRUCTION PLANS 0 SITE PLAN ❑ENERGY REPORT Z RESIDENTIAL SECTION 2 - PROPERTY OWNERSHIPJAUTHORIZED AGENT 2. Owner Record: Name (print) Contact Address T Phone Number 2.2 Authorized Agent: JD8-C77-Q'20jr, Name (print) Contact Address Phone Number SECTION 3 -CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number: Address: Expiration Date: Signature: Telephone: 3.2 Registered Home Improvement Contractor: Not Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ Yes ❑ No If No, go to the next section! Are you claming exemption from the requirements? ❑ Yes ❑ No If Yes, submit the required affidavit! Company Name: Registration Number (if none, state "none"): Address: Signature: Telephone: Expiration Date: 3.3 For Residential Remodel Work Only PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598 0 1 am a Homeowner performing all the work myself. Own3rs Name (print): Signature: By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund Date: 3.4 Homeowner Exemption - One & Two Family Only FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, 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 she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction Supervisors. 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 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 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: Your signature carries certain responsibilities, including but not necessarily limited to, general liability t✓ a NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Comstruction Supervisor_ whether or not thev have taken the nermit are recnnnsihle for rnrlP cmmnlinnnp (cee AnnanriiY of 7R0 r'.MR Pt; 9 1A) SECTION 4 WORKER'S COMPENSATION; INSURANCE AFFIDAVIT (MGL c 152 § 25) � 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: ❑ Yes ❑ No SECTION 5 - DESCRIPTION OF PROPOSED WORK Check all applicable) ( PP ) ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ W000dstove/Pellet St(bve ❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding I345ther (Energy report required) (Shed/Garage) (Specify below) ❑ Addition ❑ Replacement window/door ❑ Demolition (Energy report required) No. of windows _ Doors _ (Specify below) O A 6 o E6W *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): ❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other escription of proposed work: L S ©x6 0 SECTION 6 -'ESTIMATED CONSTRUCTION COST - Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total = 0 + 2 + 3 + 4) - -^-' SECTION 7A -OWNER AUTHORIZATION {to` be completed when owner's agent or contractor applies for building permit) (P ase Print) as Owner of the subject property hereby auth9dze �— --� to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 713 - OWNEWAUTHORIZED AGENT DECLARATION 1, L—n% ks , as Owner/Authorized Agent hereby declare that the statements and informatiron Wonforegoing application are true and accurate, to the best of my knowledge and belief. gned under the pains and penalties of perjury. Signature of Owner/Authorized Agent Date INVERT SCHEDULE LOCATION DESIGN AS -BUILT AT HOUSE 109.22 109.09 INTO TANK 109.02 108.95 OUT TANK 108.77 108.68 INTO D-BOX 108.17 108.09 OUT D-BOX 108.00 107.89 END OF MELD 107.70 107.67 I CERTIFY THAT THIS SYSTEM HAS BEEN BUILT IN SUBSTANTIAL COMPLIANCE WITH THE DESIGN PLAN AND MEETS ALL APPLICABLE LOCAL AND/OR STATE REGULATIONS.