BP-63964Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
TOTAL FEE: 7 _S Gross Area New Construction total sq. ft.
Gross Area-ggAlteration total sq. ft.
Permit Issued to: e e a oa e-, �-
Fire Chief- Signature: Date:
Board of Health: Signature: Date:
Conservation Commission:_ Signature: -' Date:
_ I
Other: Signature: Date:
Brief description of work being performed:
41
r-,-,-SECTIONM IN
FORMAN
1.1 Property Address �� ���/ /5(�� 1.2Assessors Man & L t Number:
Lot Area (sf.) Frontage Map 3Lot -
Required - Provided `
Front Yard 1.3 Historical District ❑ Yes 10 No
Side Yard
Rear Yard Year Built
❑ Altering more than 25% per side 0 building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the His toric Commission?
❑ Municipal, dPrivate Well ❑ Municipal .136n Site Disposal System ❑ Yes ❑ No Date:
I
CONSTRUCTION PLANS SITE PLAN ENERGY REPnRT
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