BP-91035RISIDENTIAL
Z21-Owner Record:
Ne (print)
Contact Address Phone Number
S
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License: License Number.
Company Name/Contractor Name: A)X
Address:
Expiration Date:
Signature: Telephone:
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
FxLeption: Any Homeowner performing work for which a Budding 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.
Fa; -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:
ature:
;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/Fireplace Woodsto /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):
❑ Bc''ier(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 urit)
❑ None of the abov— . _ d
0 Hat Water: Ga_ — _ Electric Fuel Oil Other
� •
Item
Estimated Cos
t t ($) to be completed by permit applicant:
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
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(Plea Print)
{ as Owner of the subject property hereby authorize
to act on m behalf . all matters elative to work authorized b this building permit application.
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Signature of Owner Date
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( 'p as Owner/Authorized Agent hereby declare that the statements and infofrmation
the foregoing appl' ion'are t and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
. nature of Owner/Author' d Age t—
Dee -
Less Application Fee: $25.00
Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
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Permit Issued to:�°
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Cep✓ `�d/754rC,
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T� ❑ Phased Approval (R10i�.3,3) ,
$25.00 APPLICA'1 ON FEE IS NON I6E-I'UNDABIE N.
WBANSFEEBABLE
/�itact Person: /%)gt'6 J/, Wn,, ,
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r CONSTRUCTION-