BP-95737Q� i
�1,CM:ur Record:
N ame Crorint)
Contact Address Phone Number
2.2 Authorized Agent.
Name(print) Contact Address Phone Number
4 i
QERiES t
- �x;..��_.;�;
3.1 Licensed Construction Supervisor/Specialty License: License Number.
Company Name/Contractor Name: I q
Address:
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
Exceptio; r: 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 fin a two-year period shall not be considered a Homeowner.
If ou 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: ❑ Yes ❑ No
z •ems ' .. '1ESC[4�3t`�aEIlR£ tl 1 y
epal
m :pltcatii3.. : r
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 ❑ Dumpster On Street
F "
acilit Name:
Y Location:
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. Baths
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit
❑ 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 (nombined unit) - primary fuel, natural gas, propane, electricity, other (specify);
❑ Air condt;ioning - (separate unit)
❑ None of tfre above to be provided
0 Hot Water. Gas Electric Fuel Oil Other
cam+ CH
1. Building
Item Estimated Cost ($) to be completed by permit applicant;
----
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total (1 +2+3+4)
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_. .,. _ ... .�.." .... :�_,► Ye��ti'�nth�nOVVCi EaS"� en. -:e �
(Please Print) c
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as Owner of the subject
property Y
hereby
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
...seas
/1i9T101�IE[ AGENT IDECFARATI(V
Cl as Owner/Authorized Agent hereby declare that the statements and inforrmation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Si ed under the pains and penalties of perjury.
Signatur wner/Authorized Agent Date
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $ 75'
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
P p erm' It Iss
ued to:
vP �`. � 'Y $°' u, � !�;�.: ,...x, - Y.:r K .F , .- , ., " ... ...; C :.. '':Fy.r -' :,: .. ".: ": •'4 a• G' s_ :Kt'E"' .. -., f.i......".,s �.._ �i...c.:.s., K. .. ._.z-,.. , ;:�xs :,�.i,:�..._..°��.�. .l�tl,. iu..�.s �.-:#'. .. rx . •- = t .. ' :- .,,.�.... M. y �, �, 3r ems. - eh. e.E:.:,:;
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075 it
❑ Phased Approval (R106:3.3)
1.1 Property Address: �(p ��%/� //,���f ��Y%
1.2 Assessors Map & Lot Number::
Map C7 Lot J-3 3 �
r Contact Person:
-
" -
umber:
Phone Number:
1.3 Historical District [IYew ❑ No
{
Year Built
3
1.4 Water Supply (MGL c40 s54):
1.5 Sewage Disposal System:
❑ Municipal
❑ Municipal
❑ Altering more than 25% perr side of building
❑Private Well
❑ On Site Disposal System
Has application been submitted to)'the Historic Commission?
❑ Yes ❑ No [Date:
I
plRevised 5 (13
CONSTRUCTION PLANS &SITE
PLAN U ENE T