BP-960992.1"qwner Record•
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Name (print)
A • G
2. Irized A e t:
Na m
P
rm t
3.1 Licensed Construction Supervisor/Specialty License:
Company tame/Contractor Name: L�
Address: •
Si9 nature
9_6
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101 Expiration Date:
Te
lephone:
P
ho ne:
3.2 Homer her Exemption - One & Two amily Only Section 110.R5.1.3.1
Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR
Exception: Homeowner performing work for which a Building Permit is required shall be exempt from the provisions OWN PROJECT
engages a pE son(s) or ch work, that such Homeowner shall act as supervisor. p of this section; provides that if a Homeowner
For the purposes of this section only, a °Hom " is defined as follows: Person(s) who owns a parcel of land on which
there is, or is i-Mended to be, a one or two family dwelling, atta etached structures accessory to such use and/or h he/she resides or intends to reside, on which
one home in a two-year period shall not be considered a Homeowner. farm structures: A person who constructs more than
If you are applying under this section sign below:
Signature:
Worker's Compensation insurance Affidavit must be completed and submitted
affidavit will result in the denial of the issuance of the building with this application. Failure to ovide this
ng permit. Signed Affidavit Attached: ❑
No
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5.Total=(1+2+3+4
Estimated Cost ($) to be completed b Va: •_+���'�� c�.�. _
y permit applicant
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f Pleas ri
as Owner of the sub'ectauthorize-,,,,,,,,,,
1 property hereby to act on my behalf, n all matters
relative to work authorized by this building permit application. ,
4
Signatu of Owner
t Date
- .`^ -.: •c-_ems
L-
1 <jtj
�s Owner/Authorized Agent herebydeclare
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Si ed u d7 the P ' ties of er'Jpry,
S
Total Permit Fee: $
- - r,- :r.-� =�-.�•c.; µ ,. � «vase{y�'v__=J 1�,
Less Application Fee: $25.00
Other $ Amount $
Gross Area - New Construction total sq. ,ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
107 ___ 15-
Date
Remaining Balance: $ `Z
❑ Deck ❑Poo( ❑Repairs El Alteration ❑
Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑Accessory Bldg.❑ Addition
(Energy report required) Shed/Cara ❑Roofing/Siding ❑Replacement window/door
( ge) (Energy report required) w/door
No. of windows Doors
r
❑ DEMOLITION (specify):
Location of debris reme-val (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Du mpster On Street '
Facility Name: :::.:._
"+'..F._i••i7; 1 {�=.=f•�. -`• i't'. :�::.y�-r-Li rL �•l~_ I\:.� _ f?�; �_:.... Location:.9.._-
•.'�..1i•-•e^:-:�ir� U... —cy-°`}7 = `«�.rrs'>... Q.ya _-'--^-'��-��.:.- +- ��,•i. _
-1�..;• �,� _`•�:.±:�p=. µ:IN�.�r :� arm � � _ r. �r� +-.q_.�,.��
99
•S�_'I ■1 ._ .�RFI'ilt'-• - ��5�•.__.u. .i::•r.`'_=L :.f�1 -��J� ��-"'.'. _
*If new construction, please complete the following:
Single FaMily: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 No, of Ba
ths 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 heati-� g ( propane), ( g) - fuel as natural or fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, others eci
❑ Air conditiori~n (specify):
g - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel oil
Other
sr.
Y
r
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❑ Phased Approval (R106,3.3)
$25.00 AppLICATION FEE IS NON RE-FUNDA °I E & NT®IN-TRAI�fSFER• LE
rti n -s-rr M r- P+ c 11
Board of Health: ;' Signature: 1Ud1e'
[-Date:
Conservation Commission: Signature:
D.P.W.: Signature: [Date:
Fire Ch
ief: Signature: [Date:
Other: Signature: Date:
Rrinf Anct--rintinn of work beinq Performed.
1.1 Property Address: 0
Contact Person: ',TO
Phone Number:
5o8679D55�
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
r- t T 10" h N" L A N
—
bf
1.2 Assessors Map & [Lot Number:
Map Lot
U Z.
1.3 Historical District ❑ Yes ❑ No
Year Built
❑ Altering more tthan 25% per side of building
Has application been csubmitted to -the Historic Commission"
❑ Yes `❑ No Date: