BP-84190RESIDENTIAL
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SECTIDN_2 FRCjaEiUifVNiRS�f1P�ATtiQf3iZED AGENT _
.1 Owner Record:
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Phone Number
Name (print) Contact Address
2.2 Authorized Agent:
Contact Address Phone Number
:Name (print)
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3A Licensed Construction Supervisor/Specialty License: Licens Number.
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Company Name/Contractor Name: � o
Address Expiration Date:
Signature: Telephone:
3.2 Homeowner Exemption One & Two Family Only Section I IO.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
j Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that K 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 fie/she resides or intends to reside; on which
accessory to such use and/or farm structures: A person who constructs more than
' intended to be a one or two family dwelling,. attached or detached structures ry
(here is, or is � Y
one home in a two-year period shall not be considered a Homeowner.
if you are applying under this section sign below:
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Signature:,
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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
iCEN 5 DESGRI�f'IQIV i31`_PROPE>tNFrEK.�CiteaCatipticable�
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1-1 Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ZWoodstove/Pellet Stove
0 New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (ShedlGarage) (Energy report required) No. of windows Doors
0 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):
i11 Air conditioning (separate unit)
❑ None of the above to be provided
El Hot Water: Gas Electric Fuel Oil Other
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(Please Print)
1 , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
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RECTO s
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Less Application Fee: $25.00
Remaining Balance:: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration
tal sq. ft.
� 0 —/1 �
Permit Issued to:
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