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OYERDIGf UNDE .DIG NOTE. -IN ARE
FOR A DISTANC.2' OF 5' IN ALL L
SHALL EXCAVAAPPROX. 12" Di,
_ SAND STRATA &,, REPLACE WITH ,
CLAY, FINES & 4ORGANIC MATTER
DIFFERENT CLASSES OF SOIL SA
SHALL NOT COXTAIN ANY AIATER.
�Tpp p �y��3 AND SHALL COA FORM TO THE SI
`S'Ap?IC L NG, CMR 15.255, RL'VISED TITLE 5. 1
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TO ELEVATION # 74.84 ON THE U
THE OVERDIG. AIPPROXIMATE VOL
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_ = a SErTtON.2 E?R�PERTYOWNElRSH1�lAEyT�fQRfZEQ
AfsEP1T ' - _ - -_
.1 Owner Record:
to? MSers Or0e- 617-676®
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION, t,DNSTRE7GTIN'SERYtiC$
_ _ -
3.1 Licensed Construction Supervisor/Specialty License:
S
Li c ms Number: -
.Company Name/Contractor Name: 40
Addes r s .
Expiration Date:
p
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 ,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, orris 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.
are applying under this section sign below:
ure:
V
T sE t(Q i = ltlft3�t GC Aiit?E�t�ATtt3N {fV IIf Ai�1 FZ AF Ii3A�fJT' -4
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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
QESft 3TIt31V t3F R OPf3 EQ WQRJf (Ghecfs IC ipltcatlej
�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
0 DEMOLITION (specify):
Location,
of debris removal (per MG u r On Street
(p L G.40 Sec 54). - ❑ Dumpster on site ❑ D mpste
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(hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler (hsating) - 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
0 Hot Water: Gas Electric Fuel Oil Other
Item Estimated Cost ($) to be^completed by permit applicants
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5 Total 0+2+3+4)
SFCTtfJI T 01 hlEl At _ If�Fi1ZATitJN _
m, _ ._ . �tr,be_c�npleted wfaen ownec'��tge�or c+�rttf�ctpr_�tp Tres for#iraiiddr�g petmtt} _' ; .;`
(Please Print)
1, as Owner of the subject property hereby authorize
ed b this building permit application.
to act on my behalf, in all matters relative to work authorized y 9 p PP
Signature of Owner Date
jf A
SEGT[CIV iB.aW�tER0TiiOR{ZEDC,EhT.QECARAI(3t�
Yn
!t wt 6 T t G as Owner/Authorized Agent hereby declare that the statements and informationthe foregoing 1poication are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signatur of Owner/Authorized Agent Date
sEE rraO�Mrt�>er4R�sxos
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $ ;7ir
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
t �
Permit Issued to: �-
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RePAO v IkL ex is i e �o bvi(cL o_ fw e- e e a ci
i ovll L L� e C)JS � �c> H e- 190C) l
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rl C"_nNgTRI inTION RI ANC rl.qITE PLAN ❑,ENERGY RE RT