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BP-83375
IE RES TI L SECTION 6 ESTIIUiAT U GON"all kjq CE3ST SECTION PRORIERTYOWNERShpP1AUTHOI�i EI- 2.1 Owner Record: Nary le (print) Contact Address Phone Number 2.2 Authorized Agent: "Z d C,C� AVM Name (print) �--� -� I Contact Address i Phone Number - - _ - SECTJON--GOMS7RUCTIONt=R �tiGE S - A 3.1 Licensed Construction Supervisor/Specialty License: C J Li cens Number. i. Company Name/ContractorName:' Address: 0Expiration Date: (zZ l lb Signature. Telephone:,2�-1 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 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. i 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 rovide this affidavwt will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Yes ❑ No = - �s��G'I'IQN S iJBSOR[[?T[©N (3F PF�CSP'OSEE1�14i'ORK�Ghect<"��[ a�pltcable}: - '_ - _ 'II ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) Alo. of windows _ GDoors 0- �' ❑ DEMOLITION (specify): o Loca°'on of debris removal (perMGL C.40 Sec 54): ,R(Dumpster on site ❑ Dumpster On Street Facility Name: Location: 1f new construction, please complete the following: Single Family: No. of Bedrooms No. of Baths I s 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): j ❑ Air conc_;tioning - (separate unit) j ❑ None of the above to be provided 0 Hot Wafer: Gas Electric Fuel Oil Other . Item Estimated Cost ($} to be completed by permit applicarnt 1. Building b r 2. Electrical 3. Plumbing _ 4. Mechanical (HVAC) 5. Total -0+2+3+4) ~� _EGIION Tit 0�1[I�EE�ACiT14lR17.ATlt�N ,t jta be co�rp[e#ed, tivhen.6inrnar'sgerit,or,catttractor app[>es #vru[[ding 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. I Signature of Owner Date SEGT[OrVr 7� A OuNERI7UT�[ORiZEO:GE7DECLARAT[C3h1 I, 'D I C 2mC ltn2- as Owner/Authorized Agent hereby declare that the statements and inftormation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of e 'u 9 P P P 0 ry Sig na re o Owner/Aut ze gent Date 6P��-T: A, Jva s77 �. ,,�., Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ J Other $ Amount $ n totals. New Construction ft. Gross Area - q Gross Area - Alteration total sq. fit. Permit issued to: 4�'5G cL) t eL. A"_;4b BESIDEBESIDENTIA1 ❑ Phased Approval (R106.3.3) 1.1 Property Address .3 _oc,4 � Contact Person:- V—( qWC Uf) Phone Number:4�� 1.4 Water Supply (n ❑ Municipal ❑ Private Well 1:1 CONSTRUCTION PLANS 1.2 Assessors Map & Lot Number: Map Lot 4 1.3 Historical District ❑ Yes ❑ Nio s c40 s54): 1.5 Sewage Disposal System: Year Built ❑ Municipal ❑ Altering more than 25% per side of builiding ❑ On Site Disposal System Has application been submitted to the Historic `Commission? ❑ Yes ❑ No Date: Regs4 7 , 1 0SITE PLAN0 ENERGY REPORT