BP-88140RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON RE-I'U DALE .& 1@ ON-TRANSFERARIX
11.1 Property Address: ' 'j(Zii 115 r-6t . 1.2 Assessors Ma & t Number:
Contact Person: V U.., Map Lot
IPhone Number: b ' f �• 3'1
1.4 Water Supply (MGL c40 s54): 1.5,,Sewage Disposal System:
AMunicipal Municipal
❑ Private Well 1 ❑ On Site Disposal System
1.3 Historical District ❑ Yes ❑ No;
Year Built
❑ Altering more than 25% per side of buildling
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
/4 1-je/f S 5 /13
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY RE -PORT
Owner Rec d.
( L
Name (printp
(print)
3:1 Licensed Construction Supery
NCompany Name/;Contractor Name:
Address:3f—
License:
v-9r
Contact Address Phone Number
I F
Contact Address
Phone Number
1Jfy11aLu1 + Telephone:
i�-yam
3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception:
License Number: i V 3 4514
Expiration Date:
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 in 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 dental of the issuance of the building permit. Signed Affidavit Attached: ❑Yes ❑ No
❑ Deck ❑ Pool
❑ Repairs
)<Alteration ❑ Chimney/Fireplace
❑ Woodstove/Pellet Stove
❑ New Construction*
(Energy report required)
❑Accessory Bldg.
(Shed/Gars a
9)
❑Addition ❑Roofing/Siding
(Energy report required)
❑Replacement window/door
No. of windows Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site
Facility Name:
Location:
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
❑ Dumpster On Street
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): .
❑ Beiler (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)
❑ No-ie of the above to be provided
❑ Hot Water. Gas Electric Fuel Oil
-------- Other
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4)
Estimated Cost ($) to be com
Pleas rint)
I' M as Owner of the subject property hereby authorize
to act on my beha , in all matters relative to work authorized by this building permit application.
Signature of Owner
M"frumin
x1logir'staillip[811=
under the pains
Signature of
Date
4.
t1*,uwner/Authorized Agent hereby declare that the statements mnd information
true and accurate, to the best of my knowledge and belief.
penalties of
Total Permit Fee: $ __ 71s--
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
I
Date
Less Application Fee: $25.00 Remaining Balance::.$
Other $ Amount $