BP-65574RESIDENTIAL
SECTION 2 PROPER f Y (7WNEI SHIP/AbTH[ORIZED.A'GE
2.1 1wner Record:
Name (print) Contact Address Phone Number.
2.2 Rrized entju
:
ame (print) Contact Address Phone Number
SECTIOrt 3NSTRUC tION SERV[CES
3.1 Licer:sed Construction Supervisor/S.pecialty License: /`',`%G License Number.
Comp � any Name/Contractor
l
Address: � � �, i ; // Expiration Date:
Si nature: 'V Telephone:
- u
3.2 HomeownerExempti - 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 parson(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 iss,'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 aHomeowner.
If you are rapplying under this section sign below:
Signatures
SECTION 4 - WORKER'.,S COMPENSATION INSURANCE AFFIDAVIT (MGL c;,1',52
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit w,mlll result in the denial of the issuance of the building permit. Signed Affidavit Attached: es ❑ No
a SEGIION .-.DESCRIPTION OF;PROPOSI=Lt;WQR!{ (Giieck all;applicable) 77:
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace PiWoodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding /❑Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows Doors (Specify below)
*If, new ccnstruction, 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
11 Hot Water: ` Gas Electric Fuel Oil Other
DireinnITIA1
❑ Phased Apprdval (R106.3.3)
Board of Health: Signature: Date: _
Conservation Commission: Signature: bate:
Other. Signature: Dater
Signature: Date:
Signature: Date:
Brief description of work being performed.eeFi'Z�--�� 1/l
1.1 Property Addres$r� 'fit �1wj�/�� 1.2 Assessors Map Lot Number.
'Lot Area (sf.) Frontage Map Lot"
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard a
Rear Yard Year Built
❑ Altering more than 25% per side of building,
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System ❑ Yes ❑ No Date:
Reviised 10/11
❑ CONSTRUCTION PLANS 11 SITE PLAN ❑ ENERGY REP"ORT