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RESIDENTIAL
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R A%ENT
2.1 Owner Record:
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Name (pant) Contact A dress
Noe k gD#e.Tm c,9-r1, Phone Number
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2.2 Authorized Agent: t.
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4 fi 3 el�evve S . t t�
4very,�79
Name (print) Contact Address Phone Number
:SET1f7N 3 CONSTRU77
GTIbfV S.ER1tICE
3.1 (Licensed Construction Supervisor/Specialty License:' �� ®CS,%� ��
Licens Number.
Company Name/Contractor Name: IFc6,ep
Address: 5
r p-mm vet "A E' `.'i L Expiration Date:
Signature Telephone: ("Qqz ez �//elW/�
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: Ape -son 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:
} SEC7lt3N CtMF?Elt(uA7laft lFfSlll2AfCE FFIE?fFITNIGL�"Fi §
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: Ies ❑ No
zETioN iESCrt[rtot� tF PR4isasE>ua>�c�tracr�la�Rf�C��1.. _ _
❑ Deck- ❑ Pool ❑ Repairs Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. " ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
FITION (specify):
of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
me.
N �0
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�?� ,v 1 �S Location. W �
truction; lease complete mplete the following:
: No. of Bedrooms No. of Baths
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
seTtary s �srIMATQ co -s
.,,. rxt�cTra�
Item Estimated Cost ($) to be completed by permit applicant
1. Building/2 Z�
2. Electrical / N0-0
3, Plumbing 7 S7UZ7
4. Mechanical (HVAC)
5. Total=(1+2+3+4}
`- SECTION TA-ir?I71fNERAU7Hf3RIZAT1dR! -
_ - - tube aon` le#eci +when ovlrner's � enf or aonttact ira '- _
(Please Print)
I, TA-TQt C %A C HA-Xzos as Owner of the subject property hereby authorize R®6 e er l _
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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:SECTlOIV 7B-UWNER14tlTN®RIZE[?'4GENTDECARAT10l
I, %R06p_ T- A_ '�opvoo as Owner/Authorized Agent hereby declare that the statements and inforrmation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date
_ SfvCTiON 8 ,O�'FlCE/t1�SPEC_TO�_S NOTES �- _ _ -
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.
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Permit Issued to:
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i
&-`104R 6r1��. bps 2�� -�'�co2 Pt"Tee- "B4IrF+tzo>®
JTfit3tNe.�wr—
r`1IA/0 Reo O&O INS. I►o ate,& oC_ i a 11 A'T'�,iuxsw�r,
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RESIDERESIDENTIA1 ❑ Phased Approval (R106.3.3)
1.1 Property Address: 4(- Lucy` L. c-W e Koga 1.2 Assessors Map & Lot Number: `
Contact Person: To6e2� A. Fjy9wo o Map Lot _
Phone Number:
1.3 Historical District ❑ Yes No
.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built
k Municipal ❑ Municipal ❑ Altering more than 25% per side of building
❑ Private Well On Site Disposal System Has application been submitted to the Historic Commiss4on?
❑ Yes I No Date:
R YIsed 5/1 3
000NSTRUCTION PLANS SITE PLAN ENERGY REPO