BP-23508RESIDENTIAL
2001
RESIDENTIAL
2001
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals(see project review worksheet):
5. D3ENIE seeepproject review worksheet):
6. -1 rc?2
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
9. Inspector's Signature:
ate:
SECTI 9 — APPLICANT NOTIFICATION
Applicant informed 16f above Date: b ime: Cle
Comments:
SECTION 10- OFFICE\IIYSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ 25.00
Remaining Balance: $ '—
TOTAL FEE: �'C Gross Area - New Construction total sq. ft. S74::�
Gross Area - Alteration total sq. ft. `gyp
�- C—
Permit Issued To* a- -
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
a
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE do NON-TRANSFERABILE
Zoning Review: Signature: 4! Vc DateAPR 1 ?002
eO
Energy Report: Signature: �� Date:
Fire Chief. Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED: I SITE PLAN SUBMITTED: ❑ yes ❑ no
1.1 Property Address: Z 4 G %-�k \K,\,\ 0R •-
Nearest Cross Street:
Subdivision Name: G �.,�
Total Land Area Sq. Ft.: 44 1( Z 3
1.4 Water Supply (MGL c 40 § 54):
L9'Municipal❑ Private Well
1.2 Assessors Plat & Lot Number:
Plat �S Lot
1.3 Historical District ❑ yes C o
Has application been submitted to the Historic Qommission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
L�7 Municipal
❑ On Site Disposal System
C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 19, 2001 C:\b1dg.forms\B1dgapp.res.wpd Page 1 Rew. January 19, 2001
RESIDENTIAL 2001 RESIDENTIAL 2001
SECTION 2- PROPERTY OWNERSHIP AUTHORIZED AGENT
2.1 Owner of Record:
\
�7S
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number Qp s I
Address Z 7 �j � S'� _ .�
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
Address
Signature Telephone
Expiration Date
3.3 For Residential Remodel Work Only
..
y
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 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 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 dwelline, 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 app mg under this ction s be w.
Signature:
Your signature came certain responsibiliti�incluing but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction,
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25)
Workers 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)
❑ new construction* ❑ addition 1�alteration ❑ repairs ❑ chimney/ ❑ woodlstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool & accessory bldg. ❑ replacement window/door ❑ other ❑ dem6lition
(shed/garage) no. of windows doors (specify below): (specify tbelow):
* 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
Brief Description of Proposed Work: Z Dv4QR L
7-
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildin
l O OCR
2. Electrical
2 O QO
3. Plumbiniz
2 6 Q
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $ % L( 600
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please pri \ \
�UIS
I, d\'A-N" v , 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 7B- OWNERAUTHORIZED AGENT DECLARATION
I, IR C-%tiy��p�S , as Owner/Authorized Agent hereby declare that the statements and infortmation
on the foregoing application are true and accurate, to the best of my knowledge and belief
gne er t p ins an enalties of perjury.
Sig ture of Owner/Authorized Agent Date
C `,bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 19, 2001
C:\bldg.forms\Bldgapp.res.wpd
Page 3
Rev. Janurary 19, 2001
436-I3A
o