BP-849481.1 Property Address:
Contact Person: it"094e eakraL
Phone Number: -,5VI � ��
1.4 Water Supply (MGL c40 s54): 11.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well
❑ On Site Disposal System
1.2 Assessors M &Lot Numbe
Map Ltp -_
1.3 Historical District ❑ Yes ❑ No
Year Built
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Comimission?
❑ Yes ❑ No Date:
n rnNATRI inTION PI ANR n SITE PLAN
Kevnseo o iii
❑ ENERGY REPORT
RESIDENTIAL
SEGT(O[U.2 PROFERTYaWNERSHJPIAUTNORIZEQ AGEN7 .'
2.1 Owner Record:
Name p nt) Contact dd ess
� f Phone Number
2.29 , orized Agent: �L
Name (print) J Contact Address Phone Number
SECTION Ct7N4TRUCTK-N SERVioE
5 CSSk,
3.1 Licensed Construction Supervisor/Specialty License: lm( Licens Number:
.Company Name/Contractor Name:% 4Ei ' VL % '(}� a
Address: % `'//- V '?a, Expiration Date: L
Signature: Telephone:JI
)_
3.2 Homemvn Exemption One & Two Family Only Section 110.135.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception: Ary 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:
.: �ETfON r WQR)t SEIR. NSATLEN {{�fS(lJ�A1VG,t=F11}A��T:MGL c.5 § 2l
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: Ayes ❑ No
tST16N 5 = J)ESRCQTIOIV OFROP6SED lIIF�RK (GhettJJ(appllcable} `�
❑ Deck ❑ Pool ❑ Repairs Alteration ❑ Chimney/Fireplace ❑ Woodstove/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 a5ove to be provided
11 Hot Water: Gas Electric Fuel Oil Other
r rSl<CTION
6� ESTIMAT-ED GOMSTRlJCT10�`GOST; . 3'x :„�,, '- „�= `� - -
Item
Estimated Cost ($) to be °completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
t SEGTfJ3N 7► OUI>[VERACiTHiRl►T{ON' ``
' (fQ,be coinpleteci when'owhc's"ageht of eQtttf�ctorapptres forbui[ii>Ing peimtt} . ,
(Please-RrifT)
-m
I, , as Owner of the subject property hereby authorize' / �6
to act on my ehalf, in all matters relative to work authorized by this building permit application.
C-961
Signature of Owner Date'
SEPTA 713;OWNEFt/i4UTHQRIZEQ A.,C,E IT DEC`1 ARATIOh!
as Owner/Authorized Agent hereby declare that the statements and informattion
on the foregoing Iication are true and accurate, to the best of my knowledge and belief.
Signed and pains a d en�ltie of erjury.
�IW .i 7
Signatur f wrier/A thodied Agent Date
} SEET[ON 8 eOf✓F(OFJ([�SPEt1TtR'SJYOTES:
75
Less Application Fee: $25.00
Remaining Balance: $ "
Total Permit Fee: $
Other $Amount $
Gross - New Construction total sq. ft.
Iteration
Gr. Area Alteration total sq. ft.
.r Seo—t,
Permit Issued t .
/ f,
AiOa a
Al'Alc
•.. - k} , S G4TLEa} i ' QESftRiPT_ �t �+l, tr11 #UORK BEf[+1 P---3 R D `- a � tV1.
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