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BP-88437
RESIDENTIAL ❑ Phased Approval (R 106.3- 3) $2 0,9 APPUCA'FION FEE IS NON BE-F INDA$LY, &. N®N.TRANDFERAB TE RECEIVED Board of Health: Signature: Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Fire Chief: Signature: Date: Date: Other: Signature: Brief description of work being perfonned: - 2 S�C1FtQN 1 SIT tNl 1.1 Property Address: Contact Person: ® Phone Number: --,iC _ % O 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal ❑ Private Well I ❑ On Site Disposal System 1.2 Assessors Map & Lot Number: Map Lot 1.3 Historical District ❑ Yes ❑ No Year Built ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: El CONSTRUCTION PLANS 0SITE PLAN. Revised 5113 ❑ ENERGY REP®,RT RESIDENTIAL SEr`.Tlr)N A _-FCTIMATFrt t [ �rdTofrr�ren►F.rn�r. — 2.1 Own r Record: Name (pr: t) 2.2 Authorized Agent: / Name 1print) 3.1 Licensed Construction Supery Company ':Name/Contractor Name: Address: It Ir License: Abt lIKAUTHORiZED AGEfStT, SS" Contact Address Phone Number /_�6 4 i 1-7 tic.( Ad`. rt _ 5 Contact Add ess Phone Number 50✓1 f License Number: Expiration Date: Telephone: 3.2 Homeowner Exemption - One & Two Family Only Section 11Q.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: A: iy 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 perspn(s) for hire to do such work, that such Homeowner shalt 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 in-anded 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 Nvo-year period shall not be considered a Homeowner If you are applying under this section sign below: Signature: Lafflidavit mpensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this esult in thedenial of the issuance of the building permit. Signed Affidavit Attached: E�Yes ❑ No TYtiN f�ESGR[l�TIOI QF P1l�QSVIfQRK �GhecCcalFapgcaTrle� ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding M Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows Z Doors ❑ DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): Facility Name: *If new constr ction, please complete the following: Single Family: No. of Bedrooms ❑ Dumpster on site Location: 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): ❑ 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 at,ove to be provided ❑ Hot Water: has Electric Fuel Oil ❑ Dumpster On Street Other Item Estimated Cost ($) to be completed by permit applicant 1. Building 8 7 � 2. Electrical 3. Plumbing 4- Mechanical (HVAC) 5. Total =0 +2 +3+4) g%5 SECT[©R ()WN R AjUV E�Rf2Q E[C7N `- �to be carmpleted when owner's agent olr con>'racti3K app[Ieg € frbuiiding 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 SEGTION713` _ E3VIfZEQ AGENT.D.ECLA"v10N I, jt tCt i1 vfvt c cyl 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. Signed under the pain and penalties of perjury. Signatur Own uth ized Agent Date SECT[OC+f 8dFEEltNSPEGTt�R'S NOTES Total Permit Fee: $ �� Less Application Fee: $25.00 Remaining Balance: $ Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration t tal sq. ft. Permit Issued to e4v J - - _ITfQ14y tESGRfP©lit _3»QRF[ 1ItIIEi 7C4 � �✓� n �t o 4 ilu S % r✓ !✓�4 ----