BP-74182RESIDENTIAL ❑ Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & N®N.TBANSFEBABI.F._
ECTION 1 SITE INf,QRMATION 4
1.1 Property Address:
t'S ���T 1`T/ /iv U'Z�
1.2 Assessors Map & Lot Number:
Contact Person:
x C-
Map s Lot
-�
Phone Number:
— 90U
1.3 Historical District ❑ Yes
❑ Np
�
1.4 W er Supply (MGL c40 s54):
1.5 S�age Disposal System:Municipal
Year Built
unicipal
❑ Altering more than 25% per side of buillding
❑ Private Well
❑ On Site Disposal System
Has application been submitted to the Historic
-'Commission?
❑ Yes ❑ No Date:
El CONSTRUCTION PLANS 11SITE PLAN ❑ENERGY REPORT
RESIDENTIAL
"SECTION 2 - PROPERTY.OWNERSHIPIAUTHORIZEDAGENT
.
.1 Owner Record:
�; .
�, �-
,� O
Contact Address Phone Number
Name (print)
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTIONS CONSTRUCTION SERVICES ,
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:
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,,b el
Signature:
SECTION 4 = WORKER"S,COMPENSATION INSt1RAiJCE.AFFIt}AV1T.(MGL'c '152 § 25) u =
Worke_ ^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
ySECTiON . ` OESCRIPTION'OF PROPOSED WORK -(Check
❑ 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
❑ DEMOLITION (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
❑ 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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water. Gas Electric Fuel Oil Other
✓U
SECTION 6 = ESTIMATEC CONSTRUCTION
Item Estimated Cost ($) to be completed by permit applicantt
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC) —
5. Total =0+2+3+4) i
SECTION 7A OWNER All CHORIZAT,ION;q
(t_6 cati tpieted when owner's ` geti or ccntr ctc�r` applies for building perrrtlt) . .
(Please Print)
I, 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 Date
SECTION 71§ -OWNER/AUTHORIZED`AGENT DECLARATION .„
4 d lv , as Owner/Authorized Agent hereby declare that the statements and infformation
n the foregoing application are true d accurate, to the best of my knowledge and belief.
Signed under V p ins and pen e erjury.
—
Signature of Owne A orizedP6ent 61Date
SECTION 8.- OFFfCE/INSPEOTOR`S NOTES
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
a
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