BP-95482IKSIDUTIAII 0 Phased Approval (4106.3.3)
425.00 APP11C:ATI-DIN FEE IS T-iON BE -FUNDABLE & NWIN-TR ANSTERABLE
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1.1 Property Address: -**)"I VJ0.IJ—r-(- l�V I
Contact Person: 1 ► t. 1, � �j �l -� &a'-
Phone Number: ��%7 - ri G -,� - (,e
61
1.4 Water Supply (MGL c40 s54): ( 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
1.2 Assessors Map1& Lo Number:
Map `` Lot��d��
1.3 Historical District
Year Built
❑ Yes Q—
❑ Altering more than 25% per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission,'
❑ Yes ❑ No Date:
i evised 5 /-. 3
CONSTRUCTION PLANS C1 SITE PLAN REPORT
ame(print)
eCont Addres
?Phone Number
-: d i7Yi�l�l14
3.1 Licensed Construction Supervisor/Specialty Licens n Gvw 4 h r1 ISh�. Licensey 3�.
Number: V4S -7 11__�-
Company Name/Contractor Namej,(-��
Address: 0 !� !
Expiration Date: (�
Signature:( Telephone: 57 S- 0�
3.2 Homecwner 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. 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:
f Signature:
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to pr ide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: M-6s ❑ No
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Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑:/Replacement
ood ove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition
9) (Energy report required)
(Energy report required) (Shed/Gars e ❑ Roofing/Siding window/door
No. of windows Doors
l-
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facility Name:
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 Bedrooms Unit 2 No. of Baths No. of Baths Unit 1
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify): 2
❑ Boiler (heating) — -__
( 9) -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
❑ Hot Water: Gas Electric
Fuel Oil Other
/A/. Zfe . Y C i . e