BP-52095RESIDENTIAL
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any li-ensed Constructio
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR rR52.15)
....:SECTIONA .WORKER'S;COMPENSATION-INS Ct"NCEWFIDAVIT: (MG L,6152;§ 25) ,:•:
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 '- ❑ INo
SECTION 5�bESCRIP,TION OFPROPOS.ED WORK- Check..all a l cable
= ( pp )
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace Q Woodstoxcre/Pellet Stove
0 New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify bselow)
❑Addition ❑ Replacement window/door ❑ Demolitiorn
(Energy report required) No, of windows Doors (Specify btelow)
"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 orpropane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other {
❑ Air conditioning - (separate unit)
❑ None of the above to be provided -
❑ Hot Water: Gas Electric Fuel Oil " Other
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Description of proposed work:,G
Item
1. Building
2.' Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
(Please Print)
i, �, nez
Estimated Cost ($) to be completed by permit
C < / 0 as Owner of the subject property hereby authorize
latiive to authorized b this building permit application.
3110 V
- Date
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 ins and p Ities of rjury/. ,1�
/X')
�iga�tur4of, Owner/Authorized Agent Date