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BP-60752RESIDENTIAL � ?�^ `�_� �fiQi��R.,T �•�J.��%���"JHi P!A HORf�E G f� •,: ,,.,�: -:.. .. l�� ,u� .& ._.:: r ..:F4, ,.S,EGTtON � .. - ., ;. •w .:, ,-,> 1 Owner Rec rd: Akdnhlrom a L N �, (pant) Contact Address Phone Number 2. Authorized Ag t: eNaye Lk hi &,Q (- C Name (print) ontact Address Phone Number _ ...1 CTtU,N.3..,QC1[�STRUGT1fJt�d-SER 3.1 Licensed Construction Supervisor/Specialty License : 1 / License Number: 61040 Company Name/Contractor Name: ! 1. Address`�� Expiration Date: q - ' 61,0 Signature: Telephon 3.2 Registered Home Improvement Contractor: '" Not Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No Are you claming exemption from the requirements? J7 Yes ❑ No If Yes, Go to Section 3.3 Company Name/Contractor Name: y Registration Number (if none, state "none"): 7a� Address: r^7 r Telephone' -1.� &6� Expiration Dater I 901 Signature. j 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 Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598 I 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 individua o the structural elements of building o engaged in construction reconstruction alteration, repair, removal or demolition involving g shall be engaged in directly supervising personsP 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 Constructioi 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 Homeowne 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 whit 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 tha one horne in a two-year period shall not be considered a Homeowner If you are applying under this section sign below: Signature: Your signature can certain responsibilities, including but not necessarily limited to, general liability SA. PE�NTi•O:I'., INSiJ:(t�CE-AFr"IDI�UiT. 4Ct�ls .C.,��L... _..�). ';: "'ua�-.`, �;' �` i-: .. �:. ' Workers 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: I WYes ❑ No ,., { a :'.' ,:, P:S'iP�E.IJ"11[�Rrt3:.�r:R`;[k.NL�.{'�ieaU[�i', ,N,,o�'-fi'C',...vz ECiT,,�Of'� J �r�,E,sciRi� � i��.©�.i? a.... ,,. ( .,.,. . ., ...-.� � aW ... _. ❑ Deck ❑ Pool ❑ Repairs 0 Alteration ❑ Chimney/Fireplace ❑ Woodstovre/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. 09 Roofing/Siding ❑ Other (Energy report required) (Shed/Garage) (Specify bellow) ❑ Addition ❑ Replacement window/door ❑ Demolition (Energy report required) No. of windows Doors (Specify bellow) "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 { ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Description of proposed work: J6 1 1 I M570 3a Sh�ti C I� i;��'M® r Cow /�7.auv gas Le 0►�'1 e a.. E�3'tP,�A.t`� :SECTdO11i,6...r. Item Estimated Cost ($) to be completed by permit applicantt 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total= (1 +2+3+4) X. y,.. u r td �� � �� to be,com .leted�rn�ext,o�rn r.s�a en oit cp firact• „app., -..,, g P , )�. (Please P�ri`ntt)., y, crfv� R��� Owner the subject property hereby oriz GrUA1C'(-�1 �/c%eeU G-.e to act on my behalf, in all tters relative to work authorized by this building permit application. S a u of Own Date- ... ,� <.. ,, :, . , tea. ..<, ,..... _. ..'. F2ATIOP2.. - � , ..-. � , ,, . - � QRtZEi�.AGEh�T bE,�L� ,.. ,. e,- .. � „� SECT[ON 7`B OVitltiE�?JAul4TH...- -,��.. ..... ..., , ., s and in rmation b ffo ��' � , as Owner/Authorized Agent hereby declare that the statement 1 ��if on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pain nd pe (ties of perjury. Signature of Owner/Authorized Agent Date Page 3 Page 2 RESID, ❑ Approval in Part (Per 780 CMR.5111.13) 1. Date plan reviewed: AU 1 9 7nin 2. DENIED (see project review worksheet): Date: 3. HOLD Reason:' ice" '-' Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: - Inspector's Signature: Date: All6 19 21 1.1 Property Address:1.2 Assessors Map & Lot Number: Lot Area (sf.) Frontage Map Lot - .Required Provided Front Yard 1.3 Historical District ❑ Yes ❑' [No Side Yard Year Built Rear Yard ❑ Altering more than 25% per side of building 1.4 Water Supply (MGL c40 s54)`. 1.5 Sewage Disposal System: Has application been submitted to the Historric Commission? ❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System ❑ Yes ❑ No Date: CONSTRUCTION L S LJ SITE PLAN ENERGY REPORT Page 1 rays �+