BP-85787--
;: :;h,ttna I T Ona.� tX. ST
hCldL,11E�
Crr��_ ��rvuNs�l/crTr�alzE� A
Item-A
Estimated Cost ($} to be completed b
2.1 Owner Record:. " -
P -Permit applie ant
I. Building .5�E
2. Electrical
NNa (print} Gj/ Ce l � — 3. Plumbing
Contact Address Phone Number 4. Mechanical ("VAC}
2.5 Tatai (1 + 2 + 3 + 4) 2 uthorized Agent: ..:_
-
me {print) Contact Ad ess Y. J��7T fol _
21� �% -=- _ ..= � ,.__ __e c� feted,ia�hen:oWfier's.a ent yr con#�afcfur a(�pue�iut�;bu�ldi `
hone umber (Please Print)p rm t
SECT10N 3 CDNSTAWCTtD
N SRYIE
/ as Owner of the subject Property hereby authorize
j to act on my behalf, in all matters relative to work authorized by this building permit application.
3.1 Licensed Construction Supervisor/Specialty License y
License Number: -
Company Name/Contractor Name:
la_t / yL Signature
Address: C5 _ Date
Expiration Date: P77777777777
Signatu
TIDN" -_OWNE1T/AlITH#31�rZED AGENT �ECLAR 4TIt3N Telephone: hC fo� /f
I
8.2 Ho her Exemption - One & Two Family Only Section I IO.}R5A.3.1 Exception:
as Owner/Authorized Agent hereby declare that the statements and infformafion
ant ongoing application are true and accurate, to the best of my knowledge and belief.
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
I
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 Signed engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor. g Pains and penalties Of perjury."
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 w
ore home in a two-year period shall not be considered a Homeowner./
p who c�oristructs more than Signa re Owner/Authorized Agent Date �
If you are applying under this section` -:
sign below:aFiDEitNPSC7lNafE
VI
Signature: Less Application Fee: $25.00
Remaining Balance: $
Total Permit Fee: $
c .
Other $ Amount
77 S,�C;�rOhI
Gross Area -New Construction total sq. ft.
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 Gross Area -Alteration total sq. ft.
g permit Signed Affidavit Attachedes ❑ No
t�6CTit3PT�
Permit Issued to: 9 l� ia'i Cam..
eck Ell Pool I
❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑Accessory Bldg. ❑Addition
(Energy report required) (Shed/Garage)❑Roofing/Siding ❑Replacement window/door
(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
Fac€ty Name: x ._ t;
Location: _ .:SrdDTli 9t8f4�T D I` -
A
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 1
No. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler (ft. eating) - fuel gas (natural or propane), fuel oil, electricity, other (specify)
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air cond`roning - (separate unit)
LI None of' :he above to be provided
❑ Hot Water. Gas _ Electric
— _ _ -- Fuel Oil Other