BP-72858ESI ENTI L ❑ Phased Approval (R106.3.3)
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Contact Person: DG}Nr c_ `mil Gq a c,,,, `y Map Lot -
Phone Number: _
1.3 Historical District ❑Yes ❑ No
Year Built
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal ❑ Altering more than 25% per side, of building
L (Private Well 133"'On Site Disposal System Has application been submitted to the Fdistoric Commission?
❑ Yes 0 No Datej:_
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El CONSTRUCTION PLAINS El SITE PLAN El ENERGY REPORT
RESIDENT141
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2.1 Owner Record:
Name (print)
Contact Address Phone Number
2.2 A i
uthoriz ed n .
et
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Name (print) Contact Address 612i 15 Phone Number
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3.1 Licensed Construction Supervisor/Specialty License: License Number: r -
Company Name/Contractor Name:
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Address: ,
Expiration Date:
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Signature: ' " Telephoner
3.2 Homeo her 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 tlis 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:
" a
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: &- es ❑ No
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
11 New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding O"Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Door:
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facility Name: Location:
*If new constructiczn, 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
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Item Estimated Cost ($) to be completed by permit applicant
1 Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =0+2+3+4) mac:
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(Please Print) _ I, _Po 0VwI4 Ass +i o as Owner of the subject property hereby authorize cKC} �r�&ee- �
is
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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I, [? �� as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
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SigrAture of Owner/Authorized Agent Date
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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:
-