BP-52965REMENTIAL/// L 0,
,SE..TION 2 -PROPERTY OWNERSHIP
'-
-
UTHORIZED AGENT
C SE _
CTION 4 -WORKER'S COMPENS ATION INSURANCE AFFIDAVIT (MGL c 182 § 25
'
.1 Owner Record:
Workers Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide tf',ils
a
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ Mto
Name (print) -t; n f T CAR
Contact Addres Ph Number
2.2 Authorized Agent:
SECTION 5 - DESCRIPTION OF D WORK Check all a ` ' "
( pplicablej .= x
Name (print)
Contact Address Phone Number
❑ Deck ❑ Pool ❑ Repairs LEIA]teration—j❑ Chimney/Fireplace ❑ Woodstove;,/Pellet Stove
_ . _,SEGTION 3 -:CON
„ _ = STRUCTION
SERVICES _ ` 3_
❑ New Co Accessory Bldg.
Construction* ❑ Ac ❑Roofing/Siding ❑Other
3.1 Licensed Construction Supervisor: JA /l( 7
- _
{Energy report required) (Shed/Garage) (Specify bellow)
Not Applicable ❑
Licensed Construction Supervisor. �,
q
License Number: CS
❑Addition ❑ Replacement win w/door ❑ Dem ' i
oliy
Address: /�}�/G /%�; D�
0c11t
(Energy report required) No. of windows Doors _ (Specify bellow)
b
Expiration Date:
Signature: Telephone- ; �_6_
-c�/— p` �'
*If new construction, please complete the following:
3.2 Regi ed c me Improvemen Contractor. Q
9J /�
SJD
Not Applicable ❑
Sin le Famil
g y: No. of Bedrooms No. of Baths
Are you a !Home improvement Contractor subject to (780 CMRA 10.R6)? ❑ Yes ❑ No
If No, go tothe next section!
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
Are you claming exemption from the requirements? ❑ Yes ITNo
No of Bedrooms Unit 2 No. of Baths Unit 2
If Yes, submit the required affidavit!
a
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
company Name: �,���� � �%/L��� i
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
,!
Registration Number (if none, state "none"):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
Address:1 1G �T�` ?�
J��
❑ Air conditioning - (separate unit)
0None of the above to be provided
Signature: Telephone:
Expiration Date:
❑ Hot Water: Gas Electric' Fuel oil Other
3.3 For Residential Remodel Work Only
D cription of proposed work: �T R
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
/� /�/ % !G'��/dGl�
1-lome Improvement Contractors Registration, One Ashburton Place -Room 1301 Bo ston, MA 02108, 617-727-8598
�
, . =� _ SECTION 6 - ESTIMATE:.y._ .
D;GONSTRUCTION COST
❑ I am a Homeowner performing all the work myself.
Item
_
Estimated Cost ($) to be completed by permit applicant
1. Building
C�,�_
Owners Name (pri
2. Electrical
p Coo
3. Plumbing
Signature:: r
4. Mechanical (HVAC)
signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
5. Total = (1 + 2 + 3 + 4)
,mot
fJ a
Date: dj s o2�XJ
- SECTION 7A -'O NER AUTHORIZATI ON
(to tie Completed when owner's a
p gent or.contractor applies for building permit)
73.Homeowner Exemption - One & Two Family Only
(Please Print) `
1 /as Owner of the subject property hereby authorize
to act o myb
alf, ' a I m 's rela ve t wo authorized by this building permit application.
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individualr
saeengag=,d in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involvingthe structural elements
or structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations
Sign,, r
9 e O O er Date
stbuildings
Supervisors, for Licensing Construction
Exception: An y Homeowner performingwork for which a Building
utlwne Permit is required shall be exempt from the provisions of this section provides that if a Homeowner
engages a persdn(s) for hire to do such work, that such Homeowner
SECTION 7B-,OWNER/AUT HORIZED AGENT W77 r,
shall act as supervisor.
For the purposes of this section only, a "Homeowner" is defined as follows: Persons 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 A
1, ? , as Owner/Authorized A gent hereby declare that the statements and 1Rfformation
!
structures. person who constructs more than
one home in a bvo-year period shall not be considered a Homeowner.
O e fo going application are true and accurate, to the best of my knowledge and belief.
If you are appl ' g un erjhi e n si n b
Si n u er th an penalties f perjury;
Signature:
L(/J ��
(Four si na ure c rries ain responsibilities, including but not necessarily limited to, general liability
n r of Owner/Authorize gent
Date
SECTION`8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed: RESIDENTIAL
Approval in Part (Per 780 CMR.5111.13)
$25.00 APPLI
2. DENIED (see project review worksheet : CA TION FE s E IS N - -
ON I3E FUND AIl<LE c& NON�I'ItANSFEit.4B1.'
SECTION 1 -SITE INFORMATION:
1.1 Property Addresap- 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map Lot
Required Provided
Front Yard 1.3 Historical District ❑Yes
Side Yard No
Has application been submitted to the Histtoric Commission?
Rear Yard ❑ Yes ❑ No Date:
11.4 Wat Supply (MGL c40 s54): 1.5 Sewage Disposal Syste
unicipal ®Private Well 11 Municipal p � On Site Disposail System
CONSTRUCTION PLANS SITE PLAN
❑ ENERGY DEPORT