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800 MECHANICALS & PRUMARY FUEL
Architect/Engineer.- project supervision and reports
- Furnace (hot air) - Fuel gas (natural or propane), fuel oil, electricity, other (specify)
Company name
- Boiler (heating)- Fuel gas (natural or propane), fuel oil, electricity, other (specify)
Address
= HVAC (combined unit) - Primary fuel, natural gas, propane, electricity, other (specify)
Phone number -
- Air conditioning - (separate unit)
Certified by State of Massachusetts as
None of the above to be provided
Certification number
Hot Water Gas Electric Fuel Oil Other
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
900 SPRINKLERS - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential -
- Required, -plans provided, ---plans not provided, why?
General Contractor (if Homeowner, state homeowner here then complete section 1300)
- Not required, not to be installed. Why?
Company name
Address
1000 REQUIRED OFF-STREET PARKING - for ZONING & Architectural Access
Phone number
NOT .kPPLICABLE
Construction Supervisors license number
Parking Plan submitted To - Building Department - Planning Board Date submitted
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals wind not
Number of spaces - indoors outside total provided
reproductions.
Handicap paces - required _ yes _no. If yes, how many as a part of the total required number.
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Is Route 6 (State Road) Entrance permit required? yes- no -. If yes has it been issued yes = no -.
1200 FOR RESIDENTIAL REMODEL WORK ONLY
Submit copy of application and/or permit as soon as available.
Are you a Home Improvement Contractor subject to (780CMR - 6) ? Yes No _ If no go tto next section!
1100 IDENTIFICATION (print or type except as noted)
Are you claiming exemption from the requirement? Yes No _If yes, submit the required affidavit!
Current owner -name �, iY�if,'nAl Aj (5A/?C/1ib
Ren_odel contractor name ,(please print)
addressf e�4l/G'W Reg
Address
phone f# C/ 5 --yq Sa
Registration number (if none state "none")
If corporation, officer in charge
Phone number
Architeet(Engineer - for overall design
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE
GUARANTEE FUND! QUESTIONS OR COMPLAINTS call or write:
Company name
Home Improvement Contractors Registration
One Ashburton Place - Room 1301
Address
Boston, MA 02108
(617) 727-8598
Phone number
Owners name (print)
Certified by State of Massachusetts as
Signature
Certification number
Date
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
--
reproductions.
vwv
I, the undersigned, am the owner of record or authorized lessee (provide documentation) and I have reviewed
the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this
application is true and correct and that the permit requested be issued.
Further I understand that the permit will expire in six months, from the date of issue, if no work is begun or
six months after the last inspection if work has begun and' that the permit may be extended for six months if no work is
anticipated if I request such an extension in writing. I understand that the permit may be extended only three times by
written request. I understand that once the permit expires a new application may be required, including fees and current
other requirements (including Zoning).
Name /g/x""I
Signature !_, fVew '
The above
Date
nature is my voluntary act and is signed under the pains and penalties of perjury.
Who is authorized to pickup the permit at the Building Department? (please print) 'Abz JAH (LARC.1A
Address Phone
1400 HOMEOWNER EXEMPTION - ONE & TWO FAMILY ONLY
FOR HOME ONVNERS `VHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1_1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control
in Section 127.0, effective July 1, 1982, no individual shall he engaged in directly supervising persons engaged in
construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings or
structures, unless he or she is licensed in accordance with the rules and reeulat")ns promulgated by the BBRS entitled
R::i, s and Regulations for, Licensing Construction Supervisors.
Exception: Any Home Owner performing work for which a Building Permit is required shall be exempt from
the provisions of this section: provides that if a Home Owner engages a person(s) for hire to do such work ,that such
Home Owner shall act as supervisor.
For the purposes of this section only, a "Home Owner" is defined as follows: Person(s) who owns a parcel of land
on which hershe resides or intends to reside, on which there is, or is intended to be, a one or two family dwellin , attached
or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in
two-year period shall not be considered a Home Owner.
If you are applying under this section sign below:
Signature
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any
licensed Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see
2.15.2 of section 5)
1500 COST
Cost of Improvement $
Items to be installed but not included in the above cost: Electrical S
Plumbing
HVAC
Other
TOTAL
s
Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required..
_ Demolition - describe structure
Number of dwelling units Number of bedrooms 'A separate Refuse Disposal
Declaration requh-ed. .
_ Moving - (Provide copy of D.P.W. moving license) Type of structure
from where (plat/lot or address)
to where (plat/lot or address)
Number of dwelling units Number of bedrooms per dwelling unit
_ Re -roofing - (for existing only, is included in new construction)
Number of square feet Number of layers already existing
Number of layers when complete
A separate disposal declaration REQUIRED
_ Replacement doors and windows - (for existing only) (only where doors and windows exist and will not bfe
enlarged), EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling will be -
considered as an Alteration, otherwise will he included in new construction. (see Code section 3401.10 for
residential and Article 8 for commercial)
Temporary structure - includes when allowed, trailers, tents and the like and only for limited periods of time-.
Describe
500 CONSTRUCTION PLANS
None submitted. Why?
Submitted, usually three sets required. Four sets for food service\uses. Number of sets submitted
600 SITE PLAN
❑ Not required, why?
Submitted When? _ Previously, date ❑ With this application
700 UTILITIES -
Water supply - required _ yes _ no, public ? _ yes _ no, on site well? _ yes _ no,
existing? yes no
If required and not existing have necessary permits been issued? _ no _ yes, date
(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, when -
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required _ yes _ no, public sewer _ yes _ no
private septic - on -site_ yes _ no. Submit copy of permit as soon as available.
- --
- Woodstove - used (will require inspection prior to installation), new (provide manufacturers
�
The following section for official use only.
instructions). Location(s) (list)
INSPECTORS' REVIEW
Fireplace(s) - (includes flue) List location(s)
Date plan reviewed
Game Court - describe (include overall dimensions)
30 days to review period expires
Tent, Trailer (Mobile Home) or Other - describe
_ OK to issue date
300 COMMERCIAL - PROPOSED PROJECT/USE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
— OK to issue subject to requested submittals (see project review worksheet) date
THIS SECTION NOT APPLICABLE
- DENIED see project review worksheet date
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED) (See the
Code)
_ HOLD reason (date
HOLD Subject to Zoning Board of Appeals action
Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
Comments
� Dai t&
InsPectors signature' �
97Bus'mess
-ofe' asemblvwith less than 50 occupants Medical other (see Code
Section 303.0)
Applicant informed of above - Date time staff (fax, phcone, in person)
- Educational - structure for training including child day care for those over 2 years 9 months (see Code Section
304.0)
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- Over six months since approved for issue - DEEMED abandoned!
- Factory / Industrial - (see Code Section 305.0)
Advise applicant. Hold 90 days for rbturn then dispose if not picked up.
- High Hazard - (see Code Section 306.0)
Inspector mate
II
_ Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
_ Advised applicant Date Time staff (by phone, fax or in persa)n)
= Mercantile - retail stores (see Code 308.0)
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= Residential - three or more family, hotel (see Code Section 309.0)
OFFICEVNSPECTORS NOTES
= Storage - includes garages (see Code Section 309.0)
TOTAL FEES'
_ Utility.& Miscellaneous Structures -includes tents and agricultural structures (see Code Section 311.0)
Gross area - new construction Total Sq. Ft.
- New tenant .for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35)
alteration Total Sq. Ft.
- Tent or Trailer - temporary purpose?
Permit is issued to
Other `
Descrffie the proposal briefly, INCLUDE -umber of dwelling units and bedrooms or occupant load as applicable,
Comments/notes on permit
1
also existing condition
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
New Construction and/or Addition - total gross square feet
(For commercial only total gross cubic feet) - indicate
It will be considered new construction if there an increase in square footage in addition to any
alteration(s).
c If project is an addition to existing structure - Total gross square feet of existing
FOR COMMERCIAL ONLY
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu.ft) Yes No, (If yes
see Code section 127.0). Designer to submit Code Synopsis.
Will this project require Peer review (over 400,000 cu.ft.) Yes No (see Code Appendix n
APPLICANT TO PROVIDE
..-.-
1600 TO THE APPLICANT AND APPROVAL
Date of Application submission + �%�
Plat --Z/— Lot - (i�J Street Aquifer Zone
Owner
Owner mail address-�L3�z(�a
Owner phone # - '1�.-
#######################i############i#########ii#ii#################i#iiii#i#iiii#i######i############i#i
OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictional permits or approval for your
proposed project. CONTACT THEM FOR RE RJEPW SQBIbQSSIONS.
® TAX COLLECTOR Approved L_ HOLD By Date
o Board of Appeals LEI Approved By Date
conservation Commission ❑ Approved By Date
❑ D.P.W. Water ::Approved By 17 D.P.W. Sewer Approved By Date
❑ D.P.W. Cross Connection E Approved By Date
❑ Treasurer (Bond) ❑ Approved By Date
❑ D.P.W. Engineering ❑ Approved By Date
CE3 oard of Health (well) El Approved By Date
of Health (septic) D Approved By Date
❑ Board of Health (food service) Approved By Date
0 Planning Board (parking) i Approved By Date
® .FIRE DISTRICT (I - II - III) Approved By Date
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BUILDING DEPARTMENT APPROVAL:
❑ ZONING
❑ BUILDING INSPECTORBUILDING COMMISSIONER
❑ CONTROL CONSTRUCTION AFFIDAVIT
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PROJECT SUMMARY:
new construction/ alteration/demo sewage disposal - public/private
[Alter/add interior walls] [add rooms] [add footprint] water supply - public/private well
[pool] [garage/shed/deck] [game court] [food service]
Describe
To the various departments:
This notice has been forwarded to you for your information and any appropriate action. Should you have any
questions please advise. If any reason to withhold the requested permit is found, please advise. Your assistance and
cooperation is appreciated.
The Building Department -Date sent for review — By
Iastrnetious
The applicant shall complete this application to the best of their ability prior to submission, leaving no item ®ainswered. The
Department staff will be available during regular business hours to assist as necessary. N/A should be inserted ffor those sections
which do not apply. A properly completed application will help avoid unnecessary delays. Koft Frig Ion is s2 iefaia"
(for office use only) c -� ❑ FOUPWATION ONLY
Total Cost �\ Received By -;(� Date Rec'd `%= 7- J-_
Less Application Fee'r
Total Permit Fee _.'_ __ _,-- Permit # � Issued Date
100 LOCATION OF PROJECT TOTAL LAND AREA SQUARE FEET /
CURRENT ACCESSORS' PLAT LOT ek�;_ ZONING DISTRICT
OTHER ZONING OVERLAY DISTRICTS , if applicable
NUMBER & STREET '7 � y
NEAREST CROSS STREET 1 1C U t Lk .
SUBDIVISION NAME & LOT # f,4A
or BUSINESS NAME
PREVIOUS TENANT / OWNER F R A N C 1 ion 5 A R-b i 1V i A
200 RESIDENTIAL - PROPOSED PROJECT - one & two family residence only
THIS SECTION NOT APPLICABLE
7 Single family - number bedrooms number baths
Two family - number bedrooms unit 1 number baths unit 1
number bedrooms unit 2 number baths unit 2
Accessory apartment Total gross sq. ft.
Accessory structure:
Garage - detached - attached to dwelling, dimensions L W
Carport - detached - attached to dwelling, dimensions L W
Shed - dimensions L W
Deck - dimensions L W
Gazebo - dimensions L W
Swimming pool raboe ground in -ground Size ><
Chimney - number of flues
8,