BP-66761HESMENTIAL
❑ Phased Approval (R1.06.3.3)
Realised 10/11
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
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2..1 Owner Record.-
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Name (print) Cont t Address Phone Number
_.., ... ...-: ,, SEC71C)N 3 ,CONSTRUC71{3N;5ERVICES
3.1 Licensed Construction Supervisor/Specialty License: License Number: Z o 1. ?
Company Name/Contractor Name: (/0 61 c"f l DP
Address: ,c l/ ✓ C�e� ;� <. Expiration Dater
Signature: Telephone: 2-0 '� 12. 2 -L — / - / .
3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception:
FOR HCNEOWNERS 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-y-.srpedod shall not be considered a Homeowner.`
If you are applying under this section sign below:
Signature:
.: .,. .'... SECTlON.4 = WORKER'S'COMPENSA71t�N INSURANCE AFFTI�AVIT•`(IVIGL
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failuretoprovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: t'Yes ❑ No
„ SECTION 5='OESCR1PTtON OF PROPOSED..WORK;{Check alt, appticable) , .
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
A New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
jEnergy 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 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):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combin&d unit) primary fuel, natural gas, propane,electricity, other (specify):
0 Air conditioning • - (separate unit)
0 None of the above to be provided
0 Hot Water. Gas Electric Fuel Oil Other