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BP-77919
RESIDE YI L SECTION 2 PRf3P RTY aVltNt:RSHiFJAUTHC?R1�i=D AQEI�FT 2.1 'Owner Record: Name (print) i Contact Address Phone Number 2.2 Autftorized Agent: Name (print) Contact Address Phone Number SEGTtQN 3 = �QP78TRUGi'fl�t S�R�it>E� _ _ - - 3.1 Licensed Construction Supervisor/Specialty License: License Number: d T e9 Company Name/Contractor Name: Address// 'o-Ke", er 9 Expiration Date: Signature: _,.. - Telephone/29iiK-ac✓ "� 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. 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 fun a two-year period shall not be considered a Homeowner. If you are applying under this section sign below: Signature: 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 ' SEGTI(�(+l 5 _ DESGRI.FT(QN(}F.Pi2QPUSED WaRK(Cbecicil_appitcableJ ' } ❑ Woodstove/Pellet Stove WRepairs ❑ Deck ❑ Pool ❑Alteration ❑ Chimney/Fireplace ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows _ Doors _ 1 f �..J�lJ �3 G ® DEM4LITI©N (specify): Z �M �/� A die �/si;y �i'J"t4,�'[.S• /,p<1% S% Locati n 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 ❑ Furnaces (hot air) -fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ Boiler (4eating) - 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 above to be provided ❑ Hot Walrer:" Gas Electric Fuel Oil Other RESIDENTIAL 0 Phased Approval (R1D6.3.3) Board of Health: Signature: _! V % Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: Brief description of work being performed: r