BP-77097RESIOE TIAL
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F2.1Owner Record:
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Name (print) _ Contact Address
Phone Number
2.2 Authorized Agent::
Name (pant) IContact Address Phone Number
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3.1 Licensed Construction Supervisor/Specialty Licenser License Number.
Company Name/Contractor Name: S,
Address: `71 Q UkerNA,pn,c Expiration Date:
Signature: Telephone: S-10�_3 Z2 46 Lf2� �}
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 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
one home in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
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: @01es ❑ No
�,. `- STIi3 5t S[TESDR[PFtQIV3F PfQPfED ai11QRK ��hee alr aprpl�cable . ,
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. 0 Addition &<0 fing/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 ❑ Dumpster On Street
Facility Name: Location:
'`If new construction, please complete the following:
Single Fan3ily: 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 (.iot 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
11 Hot Water: Gas Electric Fuel Oil Other
RESIDENTIAL ❑ Phased,4-)rova! (R106,3,3)
$25.00 APPLICATION IFEE IS N®F - A`E-fUNDABLE & NON -TRANSFER 3i.v
1.1 Property Address: ZO
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1.2 Assessors Map & Lot Number.
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Contact Person: ti
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Ma Lot
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Phone Number. 5'�R
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1.3 Historical District ❑ Yes
i❑ 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 WEstoric Commission?
❑ Yes ❑ No Dater
CONSTRUCTION PLANS
SITE PLAN ENERGY°f
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