BP-89336I
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RESIDENTIAL 11 Phased Approval (R106.3.3)
$25.00 AppLj[CATION FEE IS NON BE -FUNDABLE & NON -TRANS
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Chief
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Date:
Board of Health: Signature.
Date:
Conservation commission: Signature:
Date:
D.P.W.: Signature:
Date:
Fire Chief: Signature:
Other: Signature: pate:
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Brief description of work being performed:r )r
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1.1 Property Address: 60- j2 e
1,2 Assessors Map & Lot Numbe,
Contact Person: 01)gtj Map Lot
Phone Number: 13 Historical District 11 Ytes 0 No
Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: 0 Altering more than 25% Pier side of building [I
0 Municipal Municipal
[I Private Well T 0 On Site Disposal System Has application been submitted tto the Historic commission.,
[I Yes 0 No Date:
1; &JUIRevised 5 /1
2
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) Owner Record:
rr"S�i`�
Name (print)
2.2 Authorized Agent:
Contact Address Phone Number
Name (print) I Contact Address
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Na.me40ontractor Name:0.
LJ 1 /1 0
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
Estimated Cost ($) to be
Phone Number (PI e Print) - -r-'-
I, l li �I jQ % , as Owner of the subject property hereby authorize
tg act on my behalf, in all natters relative to work authorized b this building Y g permit application.
- ,
.> F cDii atian ate:
Signature:
Telephone:
3.2 Homeoviner 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.
Iffou are appying under this section sign
of Owner
76 -�
Date
1, !�(/ , as Owner/Authorized Agent hereby declare that the statements and information
on ythefogoing application are true and accurate, to the best of my knowledge and belief.
Siger the pains and penalties of perjury.
v n A 14
Agent
Less Application Fee: $25.00
Total Permit Fee: $
Othe $ Amour
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this Gross Area - New Construction total sq. ,ft.
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No Gross Area - Alteration total sq. ft. r
-
rt-,-. .zpicabt) _ a� Permit Issued to:
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition
(Energy report required) ❑Roofing/Siding ❑Replacement window/door
( gY , q ) (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: �� �� 3 r
Location: _ ��. K. r ::E fF OE['�
T �. ,
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 eir) - 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)
7-/& i �/
Date
Remaining Balance: $