BP-54636/ =SECTION 2 - PROPERTY OWNERS
IP/AUTHORIZED AGENT
2.1 Owner Record:
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Name (pri V
Con act Addre§g Phone Number
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2. Authorized
Agent, oM
'2OS STDTS CA Al . �`b iVVy
Name (print)
Contact Address Phone Number
SECTION 3_-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: b UAR.r_-,C ,nn _
Not Applicable ❑
Licensed Construction Supe sor:
License Number: C,
Address: Xs, kia4iU 'r1ya-i-moo4le A
Expiration Date:
S
/ Signature: Telephone:
3.2 Registered Home mp ovement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? 4 Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes Q No
If Yes, submit the required affidavit!
Company Name: XG 14 A WA `CA tMwJ
Registration Number (if none, state "none'):
V
Address: `% 03 )� )Azzfto J 4 U27�f
Stgnatur Telephon 9 _S S
Expiration Date: —%+ - O
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
❑ 1 am a Homeowner performing all the work myself.
Owners 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
5108.3.5 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
�l
_ SECTION 4 - WORKER'S COMPENS
A.TION INSURANCE AFFIDAVIT (MGL c 152 § 25)
Worker's Compensation Insurance Affidavit must be completed
affidavit will result in the denial of the issuance of the building
and submitted with this application. Failure to provide tthis
3ermit. Signed Affidavit Attached: ❑ Yes ❑ Mo
SECTION 5 - DESCRIPTION O
PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration
❑ Chimney/Fireplace ❑ Woodstowe/Pellet Stove
❑ New Construction* ❑ Accessory Bldg.
(Energy report required) (Shed/Garage)
❑ Roofing/Siding ❑ Other
(Specify Ibelow)
❑ Addition ❑ Replacement windo
(Energy report required) No. of windows
!door ❑ Demoliticin
Doors _ (Specify Ibelow)
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of E
aths
Two Family: No of Bedrooms Unit 1 N
. of Baths Unit 1
No of Bedrooms Unit 2 N
. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity,
ther (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, o
her (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electric
ty, other
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric F
uel Oil Other
Description of proposed work:
SECTION 6-ESTIIVIATED
CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit appllicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
hv-
5. Total =(1+2+3+4)
SECTION 7A
OWNER AUTHORIZATION..
(to be completed when owner's agent
or contractor applies for building permit)
(�lse Print)
as Owner
of the subject property hereby authorize t4 lO W,ca,/ � ►
by this building permit application. i 1 h,n lay
to act on my behalf, in all mattgrs relative to work authorized
Date
Signature of Owner U
-SECTION 7B -OWNER/
UTHORIZED AGENT DECLARATION
t S /-1t,• I � r A.,+"�( `3� M-1Owne
on the foregoing application are true and accurate, tohhe bes
/Authorized Agent hereby declare that the statements arnd information
of my knowledge and belief.
Signed under the pains and penalties of perjury.
Date
Signature of Owner/Authhorifed Agent
SECTION 8 - INSPECTOR'S REVIEWICOMMENTS
RESIDENTIAL
1. Date plan reviewed: l�% ✓2 ��c�f
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: `�%/�^/1 f=.• Date:
4. HOLD subject to Zoning Board-ofAppeals action: Date:
Comments:_
Inspector's Signature:
Applicant informed of above: Dz
Comments:!
Date:
ANT NOTIFICATION
Time: Clerk:
SECTION 10 = OFFICE/INSPECTOR
Less Application Fee: $25.00
Total Permit Fee.- $
Other $ Amount $
TOTAL FEE: `7 S Gross Area - New Construction total sq. ft.
Permit Issued to:
Remaining Balance: $ —6 `
SECTION 11--ADDITIONAL'COMMENTS/SKETCHES
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(Per 780 CMR. 5111.13)
SECTION 1
SITE INFORMATION
V-1 roperty Address: rU.ta'J go
1.2 Assessors Map & Lot Number:
"'fl �aT M C)j %k t m Vt 0a-4
Lot Area (sf.) \UqISon Frontage 9 O
Map �Z Lot -
Required Provide
Front Yard 5 6 S
1.3 Historical District ❑ Yes E-, No
Side Yard Vz5c 5
Has application been submitted to the Histmric Commission?
Rear Yard G
r-
es ❑ No Date:
1.4 Water Supply (MGL c40 s54):
❑ Municipal Vrivate Well
4 .5 Sewage Disposal System:
❑ Municipal VOn Site Disposail System
�❑ CONSTRUCTION PLANS � SITE PLAN ENERGY REPORT