BP-68347- RESIDENTIAL ❑ Phased Approval (R 106.3.3)
LJ CONSTRUCTION PLANS LJ SITE PLAN LJ ENERGY REPOR-T
RESIDENTIAL
SECTION 2 = PROPERTY QWNERSHIPJAUTHORIZEDAGENT
'
.1 0 r Record:
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Name (Print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SEGTIOPf:3 - CONSTRUC:TION
SEF�VICES,
3.1 Licensed Construction Supervisor/Specialty License: 77License Number.
Company Name/Contractor Name:
Address.-
Expiration Date:
Signature_ Telephone:
3.2 Homeowner Exemption - One & Two Family Only Section 110.135.1.3.1 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 purnnses 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 se tion sign below:
Signature: Gam'
.,,SECTION`4 -WORKER'S COMPENSATION INSURANCE.AFF QAVIT(MGL c 152 § 5.)
:'Yorker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit wr 1 result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
µ
SECTION 5L' DESCRIPTION OF PROPOSED WORK (Check elf applicable) r,
❑Alteration k
❑ Deck ❑ Pool ❑ Repairs ❑ Chimney/Fireplace Woodstove/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 construction, please complete the following:
Single Fam_ly: 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 (hat 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
SECTION fi ::ESTIMATED CoopTRUCTION COST
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4)
SECTION 7A -'.,.OWNER AUTHORIZATION _
{to. be completed when+ owner`s agent o� contractor applies . or build ng permit);
(Please Print)
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.
Signature of Owner Date
CG71T1n1U7R nwfJFR/AllITHDRI7Fn AGENT.DECLARATIiDN
n u "�=1�a 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.
Sign under the pains and penalties of perjury.
Sionature of caner/Authorized Aqerft if Date
Deb mO au
per MGL 0.40 Sr-K. r-a et ) h,2 �
n 5 ;1 kid. fully it, rtrmr.r
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