Loading...
BP-82173CTIOIV 6T11fA1 Eli tDSTR[� i>?t�l5�` _ al RESIDENTIAL Item' :Estimated Cost ($) to be't;ompleted by permit applicar;it 17 tTYEfWI31ERSH1�lAEl f HDFWFi AP pituE = _ SEGTIDN.2 PRDFE >: > t 2.1 , ),, I jil.j (�,)/y� yOwner,Recor-off / 4T 11.••��/' . � Name (print) Contact Address Phone Number - 2.2 Authorized Agent: , ,, #� � �1Z 4\dti� `� f �g f 5,zl, -Cc Ai ftk t�i `� �' ' Name (print) Contact Address Phone Number = SECTION � CUN9TRUCTIaN SERYI�iB _- _ - _ - - =cssI- Ltcens Number. d-5-68 7�2 3.1 Licensed Con StructkaApervisor/Specialty License: o JgAZOg .Company Name/Contractor Name: ii t ° p Address: -7C� A Vt 5 Via- 77 Expiration Date: -7 ��/ r A dl 1 f> 6 3 ( L4 � c� Signature: Telephone: 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 Excepafion: 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 familydwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than 9: one hone in a two-year period shall not be considered a Homeowner. If you are applying under this section sign below: 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 ;_ `. tSE��ifSN :5 gES�RIPTIOI� DF PRESP'C3S�-'i1MFOR1f �Geot€��(a�ip�licatile}-- __ �` Deck�� l- t 0 Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace 0 Woodstove/Pellet Stove G ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (ShedlGarage) (Energy report required) No. of windows_ Doors_ _- qls 1h 5V1-t-i�'1 ail' t1 l� rr—�{q &d6�,.L-� ❑ DEMOLITION (specify):6 11-= ')(6- Street Dum ster On St t on site ❑ _ Location of debris removal (per MGL C.40 Sec 54). ❑ Dumpster P � Facility Name` Location: t *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): 0_Boiiec (heating) -.fuel gas (natural or propane), fuel oil, electricity, other (specify): =- • HVAG (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil ' Other _ 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total =(1+2+3+4) _.777777777777777 SEGTIDRI D*[dEl3 AIjTFiCRfATlCII�1 _ - - dirt." erm - 'e .fisrbtri[ e-or cort�ctor a . _ feted vuhet},ownee's a ..-::.. _.. _ � (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 7777 7— EGt[©P! 7� ;f3WNEFt/ UT ORIZE� A. 5-NT QE `1.ARA lOh1 .. Q. A f1 u V%S 5 as Owner/Authorized Agent hereby declare that the statements and iirfformation on the foregoing application are true and accurate, to the best of my knowledge and belief. _ r Signed under the pains and alties ofpeury LZ Signatu of Owner/Authoriz Agent Date CT`S WDTIS - 77777=SECTION $ ;.-_ F E1tN5� E ,t3R_: Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ V Other $Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued to: r T. _. va Ravi ed 5113 r_nMATR,1CTIOM RI ANC n *;ITE PLAN ENERGY RED RTC