BP-895752.2 Authorized Agent:
Name (print) I
Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License: License Number:
Company Name/Contractor Name:
Address: Expiration Date:
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 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 tw,o-year period shall not be considered a Homeowner.
If you are applying under th'l��bn sign
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: ❑ Yes ❑ No
❑ Deck ❑ Pool ET Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition oofing/Siding ❑ Replacement window/door
w//door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows —
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54):
Facility Name:
*If new construction, please complete the following:
Single Family: No. of Bedrooms
Dumpster on site ❑ Dumpster On Street
Location:
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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil
Other
Item Es imated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4
(Please Print)
- , as Owner of the
I
to act on my behalf, in all matters relative to work authorized by this
Signature of Owner
GSG , as Owner/Authc
I,
on the foregoing application are true and accurate, to the best of my
Signed under the pains-lanvenaVeof
Signature of
Total Permit Fee: $ l r—
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
property hereby authorize
permit application.
Date
Agent hereby declare that the statements and informattion
ledoe and belief.
Less Application Feel $25.00
Other $ Amount $
4 .
%�3
Date
Remaining Balance: $
5�zelz-111�
d-4i
I
RESIDENTIAL ❑ PhaSE d Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE
f r SECi'IQ
1 �S1TE,['iV�ORMATION
� , r, ` r.. -
1.1 Property Address: /; W H-`l 0"4c-
1.2 Assessors Map &) Lot Number:
Map l Lot -
Contact Person:
Phone Number:
1.3 Historical District ❑ Yes ❑ No
Year Built
1.4 Water Supply (MGL c40 s54):
1.5 Sewage Disposal Sy
tem:
❑ Municipal
❑ Municipal
❑ Altering more than 25% per side of building
❑ Private Well
❑ On Site Disposal
System
Has application been submitted to the Hkstoric Commission?
❑ Yes ❑ No Date:
CONSTRUCTION PLANS 0 SITE PLAN El ENERGY REPO.EL