BP-759712. Owner Record:
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Contact Address Phone Number
Name (p(int)
2.2 Authorized A g en#: '
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Contact Address Phone Number
Name (print)
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Y3. 1 Licensed Construction Supervisor/Specialty License:
License Number: 1-76
ompany Name/Contractor Name: Zi2 cl-\
Address: � l n G2
lExpiration Date:
Signature: Telephone:�C,)T__) C '2 Cc
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3.2 Home -owner Exemption - One & Two Family Only Section 110.R5.1.3.1 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 i-itended to be, a one or two family dwelling, attached or detached structures accessoryto such use and/or farm structures: A person who constructs more than
- Homeowner.
o be considered a Home w
home i a ear period shall not one h n two-year P
If you are -applying under this section sign below:
Signature: e
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R G�IVI ENSATiQN INS P#D SIT:,
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1,'!/orker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes - ❑ No
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❑ Deck ❑ Pool ❑ Repairs. ❑ Alteration ❑ Chimney/Firepl ❑ Wood stove/Pe llet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition oofi /Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
❑ DEMOLITION (specify):
D m ster O n Street
it ❑ u
st r on site 4 Sec 54 : ❑ Dum e
' removal (per MGL C. 0 S
of debris r m Location P
( P ) P
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 (;got air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler (he.ating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air condit)oning - (separate unit)
❑ None of Ple above to be provided
❑ Hot Water. Gas Electric Fuel Oil Other
i . aunoing
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total +2+3+4)
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(Please Print)
I, - , as Owner of the subject property hereby authorize
'zed b this build' permit application.
t rk aut ho z
ative PP s relative P all r 9
toacto n m behalf, in a Y
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Date
wner
Signature of Owner"'
SEOTIO #;t3RI�ED_'_AENT,.DEC►RATtOt.>, ; -
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. . ,iB :-:INfER/AUT
as Owner/Authorized Agent hereby declare that the statements and informiation
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[/the foregoing applica ion are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signatu a of OwneilAutKorized Agent Date
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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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1.1V'roperty Address: If llo Vi �-o( Volli Ot%Amwl
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on ct Person: �� 1�
zhone Number: 5"6
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1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
❑ Private Well ❑ On Site Disposal System
1.2 Assessors Map & Lot Number:
Map Lot .14
1.3 Historical District ❑ Yes ❑ �.�Jo
Year Built
❑ Altering more than 25% per side of buiilding
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
Revised 5 /13
❑ CONSTRUCTION PLANS SITE PLAN U ENERGY RrEPORT
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