BP-53527SECTION 8 - INSPECTOR'S REVIEWICOMMENTS
-1. Date plan reviewed: %
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Date:.
r
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
SECTION 10 - OFFICE/INSPECTOR'S NOTES
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $ / S�
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON -TRANSFERABLE
SECTION 1 - SITE INFORMATION
1 Property Address: / IrAl L, ' f14" /7 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map ✓ Lot -
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard Has application been submitted to the Historic Crammission?
Rear Yard ❑ Yes ❑ No Date:
4 Vat Supply (MGL c40 s54): 1 Sewage Disposal Sys�nSite
Municipal ❑ Private Well ❑ Municipal Disposal Systtem
❑ CONSTRUCTION PLANS El SITE PLAN ❑ENERGY RESORT
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
s am print) —�--- %1 �t
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
3.1 Licensed Construction
Licensed Construction Sup
Address:
3.2 Registered Home Improvement Contractor:
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name:
Address:
Not Applicable ❑
Registration Number (if none, state "none"):
Signature: Telephone: I Expiration Date:
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIO S OR COMPLAINTS call or write: .
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
n
1 am a Homeowner performing all the work myself.
Owners Name (print): S, xsPt.((
i
Signature:
By sinninn the nhrnin rr,e
Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
or structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
Supervisors.
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 persons) 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 fans structures. A person who constructs more than
one home in a two-year period shall not be considered a Homeowner.
If you are app g under this section sign belo
Signature: %.-- �
Your signature carries ain responsibilities, including but not necessarily limited to, general liability
SECTION 4 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c'152 § 25)
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,
SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool vRe airs ❑ q
P Iteration ❑ Chimney/Fireplace ❑ Woodstove/pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑'Roofing%Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition �
3 Replacement window/door ❑ Demolition
(Energy report required) No. of windows Doors
(Specify below)
*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):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed work: E U CP.
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SECTION 6`- ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
0
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=0+2+3+4)
SECTION 7A - OW ER AL HORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print)
I, as Owner of the subject property hereby authorize
to act on my be'half, in II elative to work authorized by this building permit application.
Signature of Owner /
on the,foregoing application
� ted under the pains and
re of Owner/Authorized
Date
SECTION 713 - OWNER/AUTHORIZED AGENT DECLARATION .
as Owner/Authorized Agent hereby declare that the statements and inforrmation
true and accurate, to the best of my knowledge and belief.
al of perjury.
Date
Y
Y
33
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