BP-81085t
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RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON-TRANSFERARIX
1.1 Property Addre c
1 Assessors Map & Lot Number:
Contact Person: ���,��\1 � �` �, Map -,?3 Lot L% -
Phone Number:
1.3 Historical District ❑ Yes WA
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
Year Built
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of building
0-,'Private Well N(On Site Disposal System Has application been submitted to the Historic Comrmission?
❑ Yes ❑ No Date:
Revised 5 /13
El CONSTRUCTION PLANS ❑SITE PLAN ❑ENERGY REPORT
RECInCuTilll
EGTIC3N2-.PREPEI2TY6WNERSHIP/At17�10RIZED.ADEI�IT'
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2.1 Owner Record:
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:.
IF-M RI 7 i �- �1
to f _N1 1-1-7
Name (print)
Contact Address Phone Number
'- S�GT)iCN,3 C�NRTRUC�IQNS`ERYIEES -
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name:
Address: LI ' r _i: i CQ-7 2 (
Expiration Date: c�' -7 1-7
Signature" �.. �y S Telephone:
3.2 Homeowner Exemption - One & Two Family Only Section 110.R5:1.3.1 Exception:
FOR HOMEdVV`NERS WHO INTEND TO PERFORM AND BE RESPONSIBLE F R-Tlilf R OWN PROJECT
Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt ffpm th prowslons of this section; provides that if a Homeowner
engages a person(s) for hire to do such work, that such Hotnegwner shall act as supervisor
For the purposes of this section only, a "Homeowner" is defined"AaJQllows: Persent who owns a parcel of land on which he/she resides or intends to reside, on which
-structures
there is, or is intended to be, a one or two family dwelling, attached or d: %i 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 H�owner`.
If you are applying under this sectiortsign 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: k1es ❑ No
« _ . r
❑ 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_
❑ DEIMOUTION (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
❑ Fumace (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 above to be provided
11 Hot Water: Gas Electric Fuel Oil Other