BP-81749RESIDENTIAL Phased Approval (R106.3.3)
LI CONSTRUCTION PLANS W' SITE PLAN ❑ENERGY REPORT
RESIDENTIAL
2.y Owner Record:
0
(print)
2.2 Authorized Agent:
Name (print)
q
al
Phone Number
Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License: I 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 below:
Signature: _ I/ lam.
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: ❑ Yes ❑ No
. -ECTIQiV 5 = bESORtP.TIOIV DPIPROPIP4 Cf. IVORK,(Check if apji) cahu}
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
1. Building Item Estimated Cost ($) to be cc
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4)
(Please Print)
h 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
icant
01 c� try-�S" `' , as Owner/Authorized Agent hereby declare that the statements and information
cn the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Total Permit Fee: $
Gross Area - New Construction total sq. ft.
Gross Area - Alter,
Permit Issued to:
Less Application Fee: 00�
Other $ Amount $ U
Date
Remaining Balance: $70!::
❑ Nw Construction* ❑ Accessory Bldg. ❑ Addition
(Eneergy report required) (Shed/Garage) (Energy report required) ❑Roofing/Siding ❑Replacement window/door
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: = SECTfQN <D�SGRIf?7iOI Ot= UI/aRK BtfNfP�ORN(ED ,: k
Location: �
X(D Q, P1
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths C %1 chg l Ab 1 ,5);11
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
0 Hot Water: Gas Electric Fuel Oil Other