BP-81544116 �76
0-
§�A
RESIDENTIAL ❑ Phased
$25.00 APPLICATION FEE IS NOT
Ipproval (R106.3.3)
BE -FUNDABLE A NON -TRANSFERABLE
DATE RECEIVE
A,& .M _ At
/Board of Health: Signature:
Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of work being perfonned: A)&d
,�t✓�j�`
SECTION-.11 - $
TE [N bRMATION
1.1 Property Address:"
Contact Person: ^�t(.�y �i��;v` _
1.2 Assessors Map & Lot Number:
Map Lot
Phone Number: 6\a�ba ,4- w u
1.3 Historical District ❑ Yes 12.No
1.4 Water Supply (MGL c40 s54):
1.5 Sewage Disposal System:
Year Built
❑ Municipal
❑ Municipal
❑ Altering more than 25% per side of building
Private Well
�f On Site Disposal System
Has application been submitted to the Historic C3ommission?
❑ Yes ❑ No Date:
Revised 5 /13
® CONSTRUCTION PLANS ❑ SITE PLAN ® ENERGY REPORT
RF_QinFMT1A1
2.1 Owner Record:
nu -
Name (print)
Contact Address Phone Number
2.2 thorized Agent:
11-L
a �- r"C,4-
e (print)
Contact Address Phone Number
-7. __7 Z 7 _7
SECTION 3KV
3.1 Licensed Construction Supervisor/Specialty License: CS(o
License Number:
Company Name/Contractor Name: "f
�U_LAN
Address: C—::reau_
Expiration Date:
ri
Signatu Telephone:
rig: 9_._MMZ C39
3.2 Homeowner E/emption - One& Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
ExceF lion: 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 th-e 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 horn 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 Affida*Ntstlbe cdhfl� eted 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: RCYes 0 No
-bF V
6 pp-COOSPD�- otwlot*0i[a13p1tW
• Deck 0 Pool 0 Repairs ,Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove
• New Construction" 0 Accessory Bldg. 0 Addition 0 Roofing/Siding 0 Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
DEMOLITION (specify): �4011
Location of debris removal (per IVIGL C.40 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 I 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)
• Nome of the above to be provided
• Hot Water: Gas Electric Fuel Oil — Other
Estimatedcompleted by permit aPplicar-it
Item
AO
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0 +2+3+4)
SEOTtO-77 -7777777777 N
e . 66io et d-
forbuilding
Please Print)
TwOMJ-S as owner
f the subject property hereby authorize
this building permit application.
to act on my behalf, in all matters relative to Work authorized b)
Date
Signature of Ov(ner
-SECTION 713 - EWNEPJAUTHORIZED:AGRNfDECLARATfot4
ikuthorized Agent hereby declare that the statements and information
of my knowledge and belief.
as Owner/
�����'to
on th?for5eg�oing application are true and accurate, the best
Signed under ins and pena ies erjV.
0
Date
Signatu of Owner/Ruth ized Agent
. .. .... ECTION __70
-NOT
P40--tANS _,ES,
'7
Less Application
Fee: $25.00
Remaining Balance: $
Total Permit Fee: $
Other $ Amour
t $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
S C R1
IP—