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RESIDENTIFU
❑ Phased Approval (R106.3.3)
1.1 Property Address: V ill /%m,6Ackg be, /J, bAR,7- 1.2 Assessors Map & Lot Number:
Contact Person: (ga — rl-bA► AHNKAJ Map *n i( Lot � -
Phone Number: -610 S 9�A— q �.
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
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commissions
❑ Yes ® No Date:
Revised 5 /1',3
®C S L ENERGY REPORT'
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12 Owner Record:
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Name (print)'
Contact Address Phone Number
2 2 Authorized Agent:
'Name (print) Contact Address Phone Number
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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: Ary 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.
y are applying under this section si w: -
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ignature: -
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Vorker'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
_
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Wood stove/Pel let 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):
• ❑- Dum ster On Street
Location (of debris removal (per MGL C:40 Sec 54). ❑ Dumpster on site p
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 (cc nbined unit) - primary fuel; natural gas, propane, electricity, other (specify):
❑ Air condiftning - (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) V /J-4?4-{V
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(Please Print)
I, as Owner of the subject property hereby authorize
to acton m behalf, in all matters relative to work authorized by this building permit application.
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Signature of Owner Date
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�2,C667C- p414i` GEC , 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 d penaltie§ of perjury.
SI a re 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:�
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