BP-78844i
RE SIDE T
{ SECTION 2 i'ROr STY OWNERSHIPA�TTOR(ZED
AGENT
2.1 Ovrner Record
Name (print)
Contact Address -Phone Number
'h ized A ent,
9
X ut.
(print) ContaG.LAddre 1/ Phone RuK er
3.1 Licensed Construction Supervisor/Specialty License: License Numbe :
Company Name/Contractor Name -:--
I
Address: P,
rvk r
Expiration D te:
�01aOA2
Signature: Telephones y7y�
3.2 Horneo er Exemption - One & TwdVamily Only Section 110.R5.1.3.1 Exception:�17-
/19�
OWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception. Any Homeowner performing work or ding 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 s tas su ervisor.
For the par poses of this section only, a "Homeowner" is defined as follows: Person(s w arcel of land on which he/she resides or intends to reside, on which
there is, or%s intended to be, a one or two family dwelling, attached or detached structures accessory to suc rend farm structures A person who constructs more than
one home kq a two-year period shall not be considered a Homeowner.
a
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 Bmvide this
affidavit will result in the denial the issuance
of of the building permit. Signed Affidavit Attached: Ewes ❑ No
❑ Deck 0 Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition bRoofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
❑ 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:
Sifigle Family: No. of Bedrooms No. of Baths
Two Fam9y: 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):
D Boiler (h•eating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit)- primary fuel, natural gas, propane, electricity, other (specify):
0 Air concMioning - (separate unit)
❑ None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
I
Item Estimated Cost licar ($) to be completed by permit app nt
1. Building
_
2. Electrical
3. Plumbing
4. ,Mechanical (HVAC)
5. Total =(1 +2+3+4)
1-��ZJ4Tvs1�������k
'` � 2
. T�'�0�3� GESLYS �@�� ill IF+CI OYk't�iSs;��ett�ifE' CQll�f ���iEit�„f�il'1 �tY%!�t �.t � �� �.
rini)
(PiMc,!�
I,
J as Owner of the subject rope hereby authorize
�-�' property Y
to act on my behalf, in all matters relative to work authorized by this building permit application.
S" ture of Owner Date
WiROW
I, as Owner/Authorized Agent hereby declare that the statements and infformation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signa re of Owner/A6thorizefd Agent Date
•a,_�u,„_ FBI � _..�..„. T� .��., . ,.
Less Application Fee: .00
Remaining Ba an
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to;