BP-34991RESIDENTIAL
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2,45)
2004
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pr()vide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ np
❑ new construction*
(energy report required)
❑ addition
(energy report required)
❑ deck ❑ pool ,/I 'accessory bldg.
(shed/garage)
* If new construction, please complete the following:
❑ alteration ❑ repairs ❑ .chimney/
fireplace
❑ replacement window/door ❑ other
no. of windows doors (specify below):
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 (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):_
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
-7
-5 C;
Item
1 Rnildina
7. F.1Pr.trir.al
'I Plnmhinu
4 MPrhaniral (T-TVAC)
5. Total = (1 + 2 + 3 + 4)
❑ woodstove
❑ demolition
(specify below):
Estimated Cost ($) to be completed by permit applie✓ant
I * Estimated Total
(please print)
I, , as Owner t e
to act on my behalf, in all matters relative to work autholiz d y
Signature of Owner
$ /SGc>.Oo
Vec property hereby authorize
it,building permit application.
Date
I, -- , as Owner/Authorized Agent hereby declare that the statement; and information
on the foregoing applica ion are tfU and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature oT Owner/Authori
Agent
bate
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RESIDENTIAL 2004
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS MONm EFUNDABLE & NOMmT ANSFE ABLE
RESIDENTIAL
■ / /A / ONLY
$ / ' APPLICATION
'z'i:Pfir_ SON FEE
is rqoN=REFU14DA]3LE & "'qp T'' '° -* yi �'. '� ��� y_, ti;r ;�
f A5 Pi ;
�� z
„NSP'CTC)R S 1FVIW/C)MMEITS .
u, SE'T`ItN ,
H_
.. :... ..-. v :.r b,. •: .. .., m � ::. a o ..:, ;..n o, .: .:ii .:.. -.. ...:... .: Ems.
1. Date plan reviewed:
2. 30 days to review period expires:
�. OK to issue date:
4. OK to issue subject to requested submittals (see project review worksheet): Date:
.5. DENIED (see project review worksheet): Date:
6. HOLD reason: Date:
i. HOLD subject to Zoning Board of Appeals action: Date:
S. Comments:
1 9. Inspector's Signature:
Date:
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R'S RE�'IE ' BEF6RE THE ISSUANCE +JF'A, �'ERM ` `. M
a
z s
WNTAL-APPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
.)(Oard of Health: Signature: Date:
— � 7/) 1 t An _q
/`onservation Commission: Signature: Date:
Other: Signature: Date:
c
Description of work being performed: to,
NUMBER OF PLANS SUBMITTED:
1.1 Property (� CEI i1
p y Address: • d ss.
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 § 54):
❑ Municipal k Private Well
C:\b1dg.forms\B1dgapp.res.wpd
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Pl & Lot Number:
1
Pla Lo-la!02
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Hit
storic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
❑ Municipal On Sitte Disposal System
CJ
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