BP-07795800 MECHANICAL S & PRBL4RY FUEL
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)
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Air conditioning (separate unit)
_? None of the above to be provided
Hot Water Gas Electric Fuel Oil Other
goo SPRINIUYM - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
Required, _plans provided, plans not provided, why?
Not required, not to be installed, Why?
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1000 REQUIRED OFF-STREET PARKING - for ZONING & Architectural Access
NOT APPLICABLE
= Parking Plan submitted To Building Department a Planning Board Date submitted
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Number of spaces - indoors outside total provided
H-ndicap spaces - required yes no. If yes, how many as a pert of the total required number.
Is Route 6 (State Road) Entrance permit required? yes no If yes has it been issued yes no
Submit copy of application and/or permit as soon as available.
1100 IDENTMCATION (print or type except as noted)
Current owner • name llvecl
address -
phone # r'�C� i� Z EZ:i
If corporation. officer in charge
Architect/Engineer - for overall design
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
ArchitectJEngineer - project supervision and reports
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
General Contractor (if Homeowner, state homeowner here then complete section 1300)
Company name ,ar�.0
Address L-,5r
Phone number
Construction Supervisors license number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals rand not
reproductions.
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1200 FOR RESIDENTIAL REMODEL WORK ONLY
Are you a Home Improvement Contractor subject to (780CMR - 6) ? Yes No s If no goo next section! `
Are you claiming exemption from the requirement? Yes _No _,X_If yes, submit the requir d affidavit!
Ren_odel contractor name (please mint) .�a'�y � -� 's ��'•®r "� .,�
Address
Registration number (it none state "none")
Phone number
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCyESS TO THE
GUARANTEE FUND! QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration
One Ashburton Place - Room 1301
Boston, MA 02108
(617) 727-8598
Owners name (print)
Signature
Date
1300 OWMM SIGN - OFF
1. the undersigned, am the owner. of record or authorized lessee (provide documentation) and I have reviewed
the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this
application is true -and correct and that the permit requested be issued.
Further I understand that the permit will expire in six months, from the date of issue, if no work is begun or
six months after the last inspection if work has begun and' that the permit may be extended for six months if no work is
anticipated if I request such an extension in writing. I understand that the permit may be extended only three times b
written request. I understand that once the permit expires a new application may be required, including fees and current
other requirements ((iincluding Zoning).
Name v�
Signature
The above s' na a,A my voluntary act and is signed under the pains and
Penalties of perjury.
I
Date
Who is authorized to pickup the permit at the Building Department? please onnn
Ad dress Phone
1400 HOMEOWNER EMWnON - ONE & TWO FAMILY ONLY
FOR HONTE OWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT.
109-1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control
in Section 127.0, effective July 1, 1982, no individual shall be engaged in directly supervising persons engaged in
construction„ reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings or
structures, unless he or she is licensed in accords-ce with the rules and regulations promulgated by the BBRS entitled
Rules and Regulations for Licensing Construction Supervisors.
Exception: Any Home Owner performing work for which a BuildingPermit is u' required shall be exempt from
the provisions of this section; provides that if a Home Owner engages a person(s) for hire to do such work ,that such
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Home Owner shall act as supervisor.
For the purposes of this sectior, only, a "Home Owner" is defined as follows: Person(s) who owns a parcel of land
on which heishe resides or intends to reside, on which there is, or is intended to be, a one or two family dwellin ;attached
or detached structures accessory to such use and/or farm structures. -A person` who constructs more than one home in
two-year period shall not be considered a Home Owner.
If you are applying under this section sign below:
Signature
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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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
2.15.2 of section 5)
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1500 COST
Cost of Improvement
Items to be installed but not included in the above cost: Electrical 5
Plumbing
HVAC
j Other
TOTA1,
Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration requuired.
_ Demolition - describe structure
Number of dwelling units Number of bedrooms A separate Refuse Dis
Imp Posall
Declaration requhv d.
Moving - (Provide copy of D.P.W. moving license) Type of structure
from where (plat/lot or address)
to where (plat/lot or address)
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Number of dwelling units Number of bedrooms per dwelling unit
Re -roofing - (for existing only, is included in new construction)
Number of square feet Number of layers already existing
Number of layers when complete
A separate disposal declaration REQUIRED
Replacement doors and windows - (for existing only) (only where doors and windows exist and will mot be
enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling will be
considered as an Alteration, otherwise will be included in new construction. (see Code section 3401.10)for
residential and Articl- 8 fc._ commercial)
Temporary structure - includes when allowed, trailers,tents and the like and only for limited periods of* time.
Describe
500 CONSTRUCTION PLANS
_ one submitted. Why?
Sumitted, usually three sets required. Four sets for food serviceluses. Number of sets submitted
600 SITE PLAN
0
of required, why?
Sub ? — _ miffed When. _Previously, date C ,..� With this application
700 L IUXI YE.S
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Water supply - required _ yes _ no, public '. - yes no, on site well? Zyes no, ,
existing? yes _ no
_
If requiredyes, not existing have necessary permits been issued? no es date j
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(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, n7hen
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required _ yes no, public sewer _ yes _ no
private septic - on -site yes no. Submit copy of permit as soon as available. _
Woodstove = used will require inspection . prior to installation new
( q P� P ), (Provide manufacturers ..
instructions). Location(s) (list)
s
Fireplace(s) - (includes flue) List location(s)
Game Court - describe (include overall dimensions)
Tent, 'Trailer (Mobile Home) or Other describe
300 CONMMCIAL - PROPOSED PROJECT/USE INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
THIS SECTION NOT APPLICABLE
(The following descriptions are based on the Massachusetts State Building Code Articl , AS NOTED) (See the
Code)
= :Assembly - restaurant, lounge, theater, school, etc. (see Code Section 30 .0) Describe
_ ;Business - office, assembly with less than 50 occupants - indi Medical or other professional (see Code
Section 303.0)
= Educational - structure for training including child day ca a for those over 2 years 9 months (see Code Section
304.Op
Factory / Industrial - (see Code Section 305.0)
High Hazard - (see Code Section 306.0)
Institutional - hospital, nursing home, in nt day care (see Code Section 307.0)
— Mercantile - retail stores (see Code 3 .0)
Residential - three or more famil , hotel (see Code Section 309.0)
- Storage - includes garages (s Code Section 309.0)
Utility & Miscellaneous S ctures - includes tents and agricultural structures (see Code Section 311.0)
\few tenant for any the above, indicate above (see Code Section 119.0 and Zoning By-law section 35)
= Vent or Traile -temporary purpose?
- Other
Describe the proposal briefly, INCLUDE r amber of dwelling units and bedrooms or occupant bad as applicable,
also existing condition
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
= New Construction and/or Addition - total gross square feet
For commercial cal total gross cubic feet) - fe indicate.
It will be considered new construction if there an increase in square footage in addition to any
alteration(s).
If project is an addition to existing structure - Total gross square feet of existing
FOR COMHIIERCIAL ONLY
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu.ft.) Yes __ No. (If yes
see Code section 127.0). Designer to submit Code Synopsis.
Will this project require Peer review (over 400,000 cu.ft.) Yes No (see Code .Appendix I)
APPLICANT TO PROVIDE
The following section for official use only.
INSPECTORS' REVIEW
Date plan reviewed
30 days to review period expires
OK to issue date
OK to issue subject to requested submittals (see project review worksheet) date
DENIED see project review worksheet date
HOLD reason date
HOLD Subject to Zoning Board of Appeals action
Comments
Inspectors signature Date
AU G 18 19 S
Applicant informed of above - Date time staff (fax, phone, in ptdrson)
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Over six months since approved for issue - DEEMED abandoned!
Advise applicant. Hold 90 days for return then dispose if not picked up.
Inspector Date
Advised applicant Date Time staff (by phone, fax or in person)
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OFFICEUNSPECTORS NOTES
O
TOTAL FEET'
Gross area - new construction Total Sq. Ft.
alteration Total Sq. Ft.
Permit is issued to
Comments/notes on permit X
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160,0 TO THE APPLICANT/REFERRAL AND APPROVAL
Date of Application submission �
Plat Lot gStreet Aquifer Zone
•
Owner
Owner mail address
Owner phone #
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OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictional permits or approval for your
proposed project. CONTACT THEM FOR REOiJIRED SUBNnMONS.
a -TAX COLLECTOR = Approved , HOLD By Date
❑ Board of Appeals Approved By Date
❑ Conservation Commission =, Approved By Date
0 D.P.W. Water Approved By ❑ D.P.W. Sewer s Approved'By Date
❑ D.P.W. Cross Connection Approved By Date
❑ Treasurer (Bond) ❑ Approved By Date
❑ D.P.V. Engineering Approved By Date
-3 Board of Health (well) _ Approved By Date
❑ Board of Health (septic) Approved B 6�> Date
❑ Board of Health (food service) = Approved By Date
o Planning Board (parking) _ Approved By Date
® FIRE DISTRICT (I - II 11) _ Approved By Date
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BUILDING DEPARTMENT APPROVAL:
13 ZONING
a BUILDING INSPECTORBUILDING COMMISSIONER
❑ CONTROL CONSTRUCTION AFFIDAVIT
PROJECT SUMMARY:
new constructions alteration/demo sewage disposal publiciprivate
[.Altertadd interior wails] [add rooms] [add footprint] water supply - public/private well
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[pool] [garage/shed/deck] [game court] [food service]
Describe 16 2Io ao-A,atl�'CCtsls -
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To the various departments:
This notice has been forwarded to you for your information and any appropriate action. Should you have any
questions please advise. If any reason to withhold the requested permit found,; please advise. Your assistance_and
cooperation is appreciated.
The Building Department - Date sent for review (� J B
(� y
❑ FDUPIDA TION ONLY
(for of m use only) Date Reed
Total Cost $
Received By
L4= Application Fee �d Date .
Total Permit Fee S Permit #
100 LOCATION OF PROJECT TOTAL LAND AREA SQUARE FEET
CURRENT ACCESSORS ' PLAT �K LOT ZONING DISTRICT r" -�"'"
OTHER ZONING OVERLAY DISTRICTS if applicable
NUMBER & STREET y U �U/�l �e c� ✓ f
NEAREST CROSS STREET
SUBDIVISION NAME & LOT # IJ� d'►y l� A
or BUSINESS NAME
PREVIOUS TENANT / OWNER
200 RESIDENTIAL PROPOSED PROJECT - one & two family residence only
THIS SECTION NOT APPLICABLE
Single family - number bedrooms number baths
Two family - number bedrooms unit 1 number baths unit 1
number bedrooms unit 2 number baths unit 2
Accessory apartment Total gross sq. ft.
Accessory structure:
Garage - detached - attached to dwelling, dimensions L W
Carport— detached - attached to dwelling, dimensions L w
hed - dimensions L W
'Deck - dimensions L R'
Gazebo - dimensions L R'
Swimming pool above ground in -ground Size
Chimney - number of flues L