BP-84674RESIDENTIAL
12.1 Owner Record:
Name (print)
2.2 Authorized
�oent:
trizedA
�IW +�t1a�
Name (print)
.I
�Signatte eleptone
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.
Forthepurposes 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 homp1n a two-year period shall not be considered a Homeowner.
P
if you are applying under this section sign below:
nature.,
3p
33 -77z/-c9Y- Wr1
Contact Address Phone Number
Contact Address Phone Number
5
3.1 Licensed Construction Supervisor/Specialty License:
Company Name/Contractor Name:
address:
in Date:
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
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fi plac ❑ Woodstove/Pellet Stove
New Construction* ❑ Accessory Bldg. ❑ Addition 4(ofing/ling ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL CA0 Sec 54): ❑ Dum ster on site ❑Du ps er On Street
,Facility Name: Location:
*If new construction, please complete the following:
Sir.;gle 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
O Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ E-oiler (heating) fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC {combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ A;�r conditioning - (separate unit)
❑ None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
V
�; � � `•" �S�T�aM 6 _ �577�1i�1'�E�-�C%N�TI���'(i�k�4�S�; ��, .: � � -. � _:.� -
Item
Estimated Cost ($) to be completed by permit appilicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5 Total (1 +2+3+4)
-
�' �'' `eta be +cornple�ed wh�novtrner��getif��r �on�,aetor�;�pire�t�rliultdln§ pePimt} ._ __ .
(Please Print)
I, , 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.
Signature of Owner Date
- = - ;=SEGT((iN 7B �7WNEft7AI:�Tti]ti1ZED AfiErN�' DE�LARA'€14►V -
L3 I" 4.v-\ as Owner/Authorized Agent hereby declare that the statements antd information
on the foregoing application are true end accurate, to the best of my knowledge and belief.
Signed under t e pains and nalties of perjury.
Signatur ner/Authorized Agent Date
Less Application Fee: $
Remaining Balance:;
Total Permit Fee: $
��
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration;toltasq ft. i
Permit Issued to: % '
SE[TIQCStti
RESIGINTIAL
❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE- ABLE & NON -TRANSFERABLE
11. VtropPrty Address: 33 Q*, 6k-t- b-K, 1.2 Assessors Map & Lot Number. -
d�°°
(intact Person: Ma � Lot '
y- 5
ne Number: %? 5 3 iZq1
1.3 Historical District ❑ Yes ❑ No
1.4 Water Supply MGL c40 s54 1.5 Sewage Disposal System:
Year Built
� pP Y{ )� 9 P Y
❑ Municipal ❑ Municipal ❑Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commissiton?
❑ Yes ❑ No Date:
nevi ed 3 /13
LJ NSTRUCTION PL ' V� ANC SITE (PLAN E�ERCY ���-V