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2.1 Owner Record:
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Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
:Name (print)
Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License: - License Number.-
Com any Name/Contractor Name:' Fp �.�\- o�
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Address: wt.�e�c��
Expiration Date:
Signature: yj� ,c-.� Telephone:.�j
8.2 Homeowner Exemption - Qne& Tw amily Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS HO 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 persons) 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
t t-re. 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
otae home in a two-year period shall not be considered a Homeowner.
ou areapplying under this section sign below:
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Signature: Vwh
VVrorker's Compensation insurance Affidavit must be completed and submitted with this application. Failure to pfevide
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afiidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: es
!,7 _ _' SGtC3�I;'DEStPTt}N ZiF PIQPi1EII®Rlf jhe� all altcatrtej _ . ° "- -
f
eck CI 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) No. of windows_ Doors
IZ 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 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):
❑ Eoiler (heating) - fuel gas (natural orpropane), fuel oil, electricity, other (specify): rl'
A04r,ombined-unit•)---primary fuel naturatgas7�p span, eiectriciiy,-other (specify):
❑ A-r conditioning - (separate unit)
❑ None of the above to be provided
C} Fr, t Water: Gas Electric ` Fuel Oil Other
Item
1. Building
2. Electrical
1 3. Plumbing
4. Mechanical (HVAC)
5. Total =0 +2+3+4)
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Estimated Cost ($) to be completed by
(Pleas Tint)
I r as Owner of the subject property hereby authorize
to act on rrA behalf, in all matters relative to work authorized by this building permit application. r
Signa re of Owne Date
EGILQi�I�B.:4 Wt E /A11T IEi1Ftt ECt,AGE 1 @I=CL RATION
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 pains and penalties of perjury.
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Sign a re of Owner u orized Agent Date
�- Less Application Fee: $25.00 Remaining Balance:
Total Permit Fee: $ `
Other $Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
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Permit Issued to:
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