BP-928220
RESIDENTIA1 1 11 Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON RE- l'UNIPiBLE & NON -TRANSFERABLE
----,--,--,DATE RECEIVED
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Board of Health: Signature:
Date:
Conservation Commission: Signature:
Date:
D.P.W.: Signature:
Date:
Fire Chief Signature:
Date:
Other: Signature:
Date:
Brief description of work being performed,
MATIOW-,•
1.1 Property Address: kk)ICY-�AQ ISR J1.2 AssessorsMap & Lot Number:
Contact Person: \�)a Map 3 Lot (0
Phone Number: (D
1.4 Water Supply (M-GL c40 s54): 1.5 Sewage Disposal System:
0 Municipal 0 Municipal
13 Private Well 0 On Site Disposal System
CONSTRUCTION PLANS El S
1.3 Historical District 0 Yes - 0 No
Year Built
0 Altering more than 25% per side of building
Has application been submitted to the Historic Commissiorri?
0 Yes 0 No Date:
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PLAN rl ENERGY REPORT'
7
RESIDENTIAL
LITKOKIZ*Eb.
Owner Re) ld131 WCX--(J- cccl<
Name (print) Contact Address &7Phone Number
0 V
Authorize t C-09 VZQ- I.
M blmw M-W Pkd'fiLd-, MA 5D-P?qc?-&2`T
Name (print) Contact Address 0 Phone Number 57 q-(o
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3.1 Licensed Construction Supervisor/Specialty isor/Specialty License hkle License Number:
6
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Company Name/Contractor
Ad
Expiration Date: 02
Sin u
Telepho&�--,esl/ t
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 two-year period shall not be considered a Homeowner.
If you are applying under thi's section sign below:
Signature:
4
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure �o provide this
-affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: C-43 Yes 0 No
10 Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove
17 New Construction* 0 Accessory Bldg. 0 Addition 0 Roofing/Siding 0 Replacement window/door
(Energy report required) (Shed/Garage) (Energy report require ---
> Sw- 2o. of windows Doors
0 DEMOLITION (specify):
Location of debris removal (per MGL CAO Sec 54): 0 Dumpster on site 0 Dumpster On Street
Facility Name: Location:
1f 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
0 Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
0 Boller (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
0 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
0 Air conditioning - (separate urit)
0 None of the abcw- VShftk4.d
0 Hot Water: GS�. Electric Fuel Oil Other
Item
Estimated
Cost to be completed by permit applicant
1. Building
ku
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(l +2+3+4)
eart
(Pleas,
I,— oas Owner of the sub
to act on my behalf, in all matters relative to work authorized by this builc
%9JL ()tpZ—V-kk-
ect property hereby authorize
ing permit application.
Y9
Date
Signature of Owner
7 71,
7�77RATION
-OWN8WAU Qllill2ff�—o
"SIECTION-713 TH
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1, �f)Cja 6 b 0 &,CI -6 , as Owner/Authc
on the foregoing application are true and accurate, to the best of my
Sigpq under the pains and penalties of perjury.
re of Owner/Authorized
Total Permit Fee:
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq./ft.
Permit Issued to:
Less Application Fee:
Other $ Amount $
il
ahsw
�C- VON
Agent hereby declare that the statements and information
ledge and belief.
11
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Datf
Remaining Ba face: $
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