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BP-75695REST ERTIAt ' { T ©iNlV1�12S1F( Tf�i@3N1CAm 2.1 Owner Record: k- t w— i t w. S .o r ✓ N 21 c> 6 �, e . C, ,/ . .SO 1 'to 15, 7 L a e (print) • t'�1 ✓ `� Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number i I..�-��L ,al "� �a,-�J� �� = k! T �� '� � !a- ��Ia. �a;�- ,a,� ._ , d��r-. -�wJ-. �L- . 'P__� _, ..._. �..:...._ - .,.'Ia �, / 3.1 Licensed Construction Supervisor/Specialty License: I License Number: LS Company Name/Contractor Name: {- .,� ✓ ' c 4 ✓1- Q �/'7 3 Address: L /., a (� P u/ Expiration Date: Signature: Telephone: 3.2 Homeowner 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 perscn(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 int=coded 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 one home in a tvmo-year period shall not be considered a Homeowner. If -you are applying under this section sign below: Signature: V ae� Worker'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 .2:. �� .a _ m L ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows_ Doors_ ❑ DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumppster On Street Facility Name: ei (-e c ,-, v-- Location: 1-nLI(,( *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 (h;�it air) - fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ Boiler (heaing) - fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ HVAC (cornbined unit) - primary fuel, natural gas, propane, electricity, other (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided 11 Hot Water: Gas Electric Fuel Oil Other IR 1 �i � ;IJ __ - ., Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5 Total = (1 + 2 + 3 +a4) K 'e1- 1 106 h e�I�'�- !4,=� (Please Print) W jNt << a �L ./ � , as Owner of the subject property hereby authorize I, ,,,,� e, t work authorized b this building permit application. to act on my behalf, In all mtester/s relative to wo y g p pp Signature of Owner Date , =L A� --! 7 a �- t�NLWL i� d`�'_ - Rs�-=�'' ��) s �5 `I IRS N: aI as Owner/Authorized Agent hereby declare that the statements and inforymation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Signature of Owner/Authorized Agent Date cI �r'3 9 2 ,¢IJ9�. E�� 3 '- , 14 Fv� `� Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration t tal sq. ft. Permit Issued to: � i A yo 1NO OMAN DESIDENTIM ❑ Phased Approval (R106.3.3) - _ � tea:, � �' t`fN� �t�N �� 1`56�, � �� . _ 1.1 Property Address: Z 7 ayt U t 1.2 Assessors Map & Lot Number: � Contact Person: ��. �� ! ',, Wt. Map Lot Phone Number: 5136 - � 1.3 Historical District ❑ Yes 07'No 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ Municipal ❑ Municipal ❑ Altering more than 25% per side of building ❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: CONSTRUCTION PLANS SITE PLAN ❑ENERGY �EPDI?T-�, /� CIUr