BP-75424RESIDENTIAL ❑ Phased App (Ioval (R106.3.3)
$25.00 APPLICATION FEE IS NON Bt-FIJNBABLE & NI
V Cgntact Person: _
0 CONSTRUCTION PLANS
❑ $ITE PLAN
Re,vised 5 /13
❑ ENERGY REPORT
RESIDENTIAL
SECTION Z = PIZOpERT1F.OWNERSHIP/AU7HORfZED
AGENT,.--
2 1 Owner Record:
A. wc� t� Sag Co3CQ- &79
Name (print)
Contact Address Phone Numbe
2. Authorized Agent:
C(,1 i
S019
(ec� �n�cr,i 3 -SSA
vvc
rly 5 e lam(
Name (print)
Contact Address Phone Number
SECTION 3 ;CONSTRUCTION SER -1 ES
3.1 Licensed Construction Supervisor/Specialty License:
t
License Number: 5L - O9 t /
Company Name/Contractor Name: AshrAwc,,Cdoinf
Address: -)O 5+C" ' '(+V i� 2 y �%
Expiration D te-
�Z 2�e 5
Signature: Telephone: q-Sj-`77
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 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 ❑ No
SET,tON S-,bESCl2tPTlO�i`OL` PROPQSED WORK_(Gheck allpp!(cab(
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace Wwoodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows_ 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'
SECTION' 6 ES fIMAT ONSTRUC?ION COST , .: .,
Item I Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1 +2+3+4
(Please Print) l
I, �V c�\4 Sq(Mef\ ID' as Owner of the s bject property hereby authorize f�/1 �W�tTy2'(Cf yWq'j
to act on my behalf, in all matters relative to work authorized by this bl. ilding permit application.
Si e o Owner Date
SECTION 7B OWNER/AUTIJA ti ED AGENT DECLARATION„
I /► I J`^'� �'r+ CNI1M as Owner/Authorized Agent hereby declare that the statements and informatiion
on the foregoing application are true and curate, to the best of my k owledge and belief.
Signed under the pains and penalties of perjury.
Signature Owner/Authorized Agent Date
„ `SECTION 8OFF(CE/l SPECTOR`.SNOTES
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration
Permit Issued to: e
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