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BP-85417RESIDE TI L ❑ Phased Approval 106.3.31 $25.00 "PLICATION FEE IS NON ICE-F ABLE777, E� 1®T®1�• �9TnQE� Contact rerson: 0 CONSTRUCTION PLANS am Revised 5 /13 ❑ ENERGY REPORT ;11UN G!U5T 2.1 Owner Record: ZY a:k MQY- t av .157 Name (print) Contact Address I y Phone Number 2.2 Authorized Agent: Name (print) 3.1 Licensed Construction Supervisor/Special Company Name/Contractor Name: V Address:, (- �n'L �( (?-A C IContact Address ECT1ON 3 ti. CONSTRUPV0N SERVIC License: 0 License Number: 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1+2+3+4 Phone Number (Please Print) `. as Owner of the subject to act on my behalf, in all matters relative to work authorized by this building Date: // %I __7 �I Signature: $ Telephone: �YOl3 3 %1�'jG 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 ch 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: 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 llo _ _ � `,,$E`CTft�N 5--DESCRIPT'1O(V. CF PRQPf1SEE? iN©R}f,�Check al('�pplicatrle) _ _ . � _ ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition y (Energy report required) (Shed/Garage) Ener report required) ❑Roofing/Siding Replacement window/door ( gy p q ) . of windows 3 Doors ❑ DEMOLITION (specify); ocation 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 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):. 0 Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas - Electric Fuel Oil Other Signature of Owner I , as Owner/Authorized Agent h reby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge ar d belief. Signed under the pains and penalties of perjury. Signature of Owner/Authorized Agent Total Permit Fee: $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued to: I Less Application Fee: $25.00 Other $ Amount $ .11 Date Remaining Balance: $ a G _ _ _ _ 'SECT,IOtd 2 = Pf�OPERTY�IU{It�tERSHIPIACiT1-fORf�Ef? +GENT. __ _- • � - C� 2.1 Owner Record: t J57 -VAY Name (print) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number a .SECTION 3 4 GONSTftUGFt(3N S RVICES,' _ 3.1 Licensed Construction Supervisco'r/Specialty License: License Number: ' B i Company Name/Contractor Name: !J �J�CK `�cIZ Vim- Address:,?(-rte �� E-�sZ ,,,, �! •expiration Date: �v �. Signature: AL Telephone: -yOC 3 %cl�j' L 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 dwelling, attached or detached structures accessory to such use and/or farm structures: A person who constructs more than there is, or is intended to be, a one oyseion one home in a two-year period shall idered a Homeowner. If you are appl i g u d r isign. Blow: Signature: SETION WOf2[Ef'S C4MFENSATIONINSUl2ANGEFFI669IT (MGL 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 Wo -SE+vTi([�[ 5_ESCRtPT[ON t1F I'ROPt SEF}_aNOR}f(Chec(i =all appltcahle) . , . F[01D ck ❑.Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding XReplacement window/door (Energy report required) (Shed/Garage) (Energy report required) b.ofwindowsS 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 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 0 Hot Water. Gas Electric Fuel Oil Other Item Estim Cost ($) to be completed by permit applicant 1. Building r oC) 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total =(1+2+3+4) SECTION TA OWN C�THOIiIZATION If be coin feted whnt or c rittaetor applies FotiuDdirig permit) (PleWn111 ►� I,as Owner of the su je property hereby authorize _ U 1 GL l" l � Clay to aers r lative work authorized bythis buil ling permit application. 2Si nDate SEGTIC3N'7B-.UWNEfz/�4UTHORI EQAGENT DECLARATION? pjj f�'1 p11 11i-!L"I-V/ 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. 4ro s and penalties o rj q 27 uthorized Date SECTION $ vjOF.FiCElINS ECTOf2'.tNOTES Total Permit Fee: $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued to: Less Application Fee: Other $ Amount $ Remaining Balance: $