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BP-78515RESIDENTIAL ❑ Phased Approval (R106.3.3) Contact Person: cy'C} rCL Vq o SITE PLAN Reviso.d 5 /13 P-ENE-RGY REPORT RESIDENTIAL - = u SIiTi�3N .;ES11(liD-061V$TRC?IBAtCOST r SECTION 2 �.PROPE T1r_OWNER$HIP/AUT 10 I EL? Item Estimated Cost ($) to be completed by permit applicarnt 1 Owner Record 1. Building t 500 — U�yr Sc� GC 1�C ® 3 c�C �� "1 2. Electrical --� 3. Plumbing ✓'— I + _ Name- (print) Contact Address Phone Number 4. Mechanical (HVAC) ✓ 5. Total=(1+2+3+4) 2.2 Authorized Agent: SECTION 71 .Q11liNERA�3T1{ORfZATfi1577777777 � h 7 _- {ta lie co�ripieteci.tivhen ovv�ers anent ar=carltr�ct�r5w apPti�s #o braitdir�� permit} _ - Name (print) Contact Address Phone Number (Please Print) SECTION 3 ;= CONETRUG714N S#=EVICfS = - I, 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. 3.1 Licensed Construction Supervisor/Specialty License: License Number: Company Name/Contractor Name: Signature of Owner Date Address: Expiration Date: SECTION 7B=:©WNER/1t1THORIZEQ;AGEN7 DECLARATION;_ Signature: Telephone: I , as Owner/Authorized Agent hereby declare that the statements and infformation a4a 0!9 0 3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception: on the foregoing application are true and accurate, to the best of my knowledge and belief. FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: Any Homeowner Signed u der t Z pains and penalties of perjury. 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 �ignaftrl`e(& th re 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 MnAuthorized Agent Date ne home in a two-year period shall not be considered a Homeowner. If you are applying under th• ection sign belor Signature: Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ J Other $ Amount $ _ SEGTf0N 4 ..;WORKER';syC.tOM�?ENSATOIV'MS�1RAlVGEAFFIQAE(IT (I(►1Gt.5 § 25) . _ Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. t affidavit will result in the dental of the issuance of the building permit. Signed Affidavit Attached. ❑ Yes ❑ No _ SCT1E3tV 5==DE$CRIFTIpN t3F .PROPOSED UHORK(CheiikIl applicable Permit Issued to: 2 ❑ 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 ❑ DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street :, , . SEGTIOit 9 =' pESGI3IPT101V QF11tORK BEING PEP2E0RIIIitD Facility Name: Location: .._ *If 1� 4 tj I C'j •ti �n �k rat C'.: A e c�-(^.,,� _f S o� �oC new construction, please complete the following: S r / Q Single Family: No. of Bedrooms No. of Baths vLQt� d lt,� !� �f'`r'• Wa�t� 4� 'IvSv.`ldf Q t�ec.. s�, t• R ��' •4 Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 1��� wQ�� w AG\ No of Bedrooms Unit 2 No. of Baths Unit 2 O Fumace (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 13 Hot Water: Gas +�1 Electric Fuel Oil Other