BP-84424RESIDENTIAL
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.. SE.CTION; 2 PR(3PE#�TY�WNERSHIPIACIT . ORi D-` >- =- - _
N _ .,�E _ifsENT
Item
Estimated Cost to.ti d by permit applicant
($) e complete
2.1 Owner Record.
1. Building
2. Electrical
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3. Plumbing
Name (print)
Contact Address Phone Number
4. Mechanical (HVAC)
5. Total =(1+2+3+4) 0E�
2 Authorize 2 rze ent. \
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Name (pant) Contact Addres
C� 5,'C %� / h n Numb
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(Please Print)
f, as Owner of the subject hereby
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property authorize
` ;; „ SECTIdI-GNSTRUGTIIIN "SL`-EYICE _.: =
o a ve to work authorized b this buildin e i a I'c '
t ct on my behalf, in all matters relate y g p rm t pp r atlo .
3.1 Licensed Construct! cm Supervisor/Specialty License- Licen Number
Company Name/Contractor Name: r c �'�i S , ``-
Signature of Owner
Date
Address.:
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Expiration Date: _
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Signature: g Telephone: ' Ce ®'L
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1, r;?� 1t i�rr6_`� � l '� as Owner/Authorized Agent hereby declare that the statements and information
3.2 Homeowner Exemption - ne & Two Family Only Section 110,R5.1.3.1 Exception:
on the foregoing application are true ,end accurate, to the best of my knowledge and belief.
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception. Any Homeowner performing work for which a Building Permit is requited shall be exempt from the provisions of this section; provides that if a Homeowner
Signed urn he pains and pen ry.
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 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
at e of Owner/ uthorized Agent Date
one home in a two-year period shall not be considered a Homeowner.
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sEeTiaty s ol�t=���r��tsPF�`r4Rs �roT� ,,
If you area pplying under this section sign below:
Less Application Fee: $25.00
Remaining Balance: $
Signature:
Total Permit Fee: $
Other $ Amount $
VJff?KEFRtMF1.4AlN{(tiIS1lG}AFFI[?R/1T;_?ILc
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
affidavit m11 result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
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... _ DESGRt�'TtIIt�l„OF.FR4PLi�E�7 NFC�f (Ghe�te�lif a , licable - -, .,
Permit Issued to:
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
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❑ New Construction* ❑ Accessory Bldg. ❑ Addition L`]<oofing/Siding ❑ Replacement window/door
(Energy report required), (Shed/Garage) (Energy report required) No. of windows Doors
i .ol�ta�e
❑ DEMOLITION (specify): e ' ;� I; O/J.
Location ) f debris removal (per MGL C1 Sec 54): aLumpster on site ❑ Dumpster On Street
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SI_STI_ ::._ DESi� PTIINBEt[+tEk� E }
Facility Name:--- -�' ��-�_ � l Location:
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*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):
❑ Boiler (heat_ng),- fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (com5ined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air condition7rig - (separate unit)
❑ None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
1.1 Property Address: % C- . �° �, � Assessors Map & Lot Number.
Contact Person: e eF► Map j Lot
Phone Number: Zz �-6 M`
1.3 Historical District ❑ Yes ❑ No
1.4 Water Supply (Mk. GL c40 s54): 1.5 Sewage Disposal System: Year Built
❑ Municipal ❑ Municipal ❑ Altering more than 25% per sit(de of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the; Historic Commission?
❑ Yes ❑ No Datte:
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El CONSTRUCTION PLAINS SITE PLAN ENERGY REP '