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RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25-00 APPLICATION FEE IS NON RE-FENDASLE & NON
1.1 Property Address: /�P�'L//��/,������[ f 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map Lot
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard
Rear Yard Year Built
❑ Altering more than 25% per side of building,
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has ap Y
ion been submitted to the Historic Cormmission?
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System Yes ❑ No Date:
❑ CONSTRUCTION PLANS
❑ SITE PLAN
❑ ENERGY REPORT
RESIDENTIAL
N
2.1 Owner Record:
`(\,
Nae (print) Contact Address
2.2 Authod ed Age
V Z A
Name (print)
3.1 Licensed Construction Supervisor/Specialty License: License Number
Company Name/Contractor Name:
Address: Expiration Date:
Signature: Telephone:
3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception
Item
1. Building
2. Electrical
3. Plumbing
Phone Number 4. Mechanical (HVAC)
5. Total=(1+2+3+4
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception: Any Homeowner performing work forwhich 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 landon 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 horse in a two-year period shall not be considered a Homeowner.
If you are applying under this section
1
Signa*ure:
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
0 Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage)
(Specify below)
❑ (Energy report required) Addition ❑ Replacement window/door Demolition
No. of windows Doors
( pecify below)
'If new construction, please complete the following: a'L�
V
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 (beating) - 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
❑ Hot Wafer: Gas Electric Fuel Oil Other
Estimated Cost ($) to be completed by permit a
(Please Print) -
1, as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
•'s
on
Date
as Owner/Authorized Agent hereby declare that the statements and inforrmation
are ae and accurate, to the best of my knowledge and belief.
Total Permit Fee: $
Less Application Fee: $25.00
I��
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to.-
Date
Remaining Balance: $ --�
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