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BP-89035RESIDENTIAL 2.1 Owner Record: .s t Name (print) 2.2 Mrized Age Name (print) �Sr- i >n/A ouBq Lei. Contact Address Phone Number . 77 Pb # J Phone Number 3.1 Licensed Construction Supervisor/Specialty License: License Number - Company Name/Contractor Name: - Q/A f ' � J"? Address: Expiration Date: //0 ) IRO)© Signature: Telephone: 77q-g30,M(? 5 J 3.2 Homeo ner 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 persom(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: . I Signature: 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 ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition & oofing/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): PlDumpster on site ❑ Dumpster On Street Facility Name: A [�� Location: "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 13 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 Item 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1+2+3+4) (Please Print) 1, to ct on my be alf, Signature of Owner Estimated Cost ($) to be ;n - , as Owner of the subject property hereby authorize in all matters relative to work authorized by this building permit application. 4a 9 P Date } as Owner/Authorized Agent hereby declare that the statements and informattion on the forgoing application are t e and accurate, to the best of my knowledge and belief. Signed k the pains and penalties of perjury. vwi icnHutnonzea Agent Less Application Fee: $2"T— Total Permit Fee: $ Other $ Amount $ J Gross Area - New Construction total sq.,ft. Gross Area - Alteration total so. ft. i Permit Issued t -, (, / , e). ©/, � " JF— Date Remaining Ba ce $ ❑ Hot Water: Gas Electric Fuel Oil Other RESIDENTIAL ❑ Phased Approval (R106,3.3) $25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON-THANSFERAB FE'F _ a El Board of Health: Signature: Conservation Commission: Signature: D.P.W.: Signature: Fire Chief: Signature: Date: Date: onheCiion`�: k 1 Property Address:Q(l 1.2 Assessors Map & Lot Number: Contact Person. (� Map —�L Lot �— Phone Number: 1.3 Historical District [I Yes 10 No Year Built Water Supply (M'GL c40 s54): 1.5 Sewage Disposal System: ❑ Altering more than 25% per side off building ❑ Municipal ❑ Municipal g ❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission` ❑ Yes ❑ No Date: 5 �._ f jP evised 5 11 El ST�RUCT°I®N PLANS 0 SITE PLAN U ENERGY REPORT