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BP-83838
j RESIDENTIAL SECTION '= PR 3Pl�RTYt)WNERSHW AUTHORIZE®,CENT 2.1 Owner Record: f � ►<+ I Rousseay 6k Tnavfh M4 Od-7,17 Name (print) Contact Address Phone Number 2.2 Authorized Agent:-C�1`'GZ/� �� r•SD o?(O �}/bio✓] o (!fp/� Name (print) Contact Address Phone Number SECTI®N 3, = CQNSTRUCTIQN SERVICESA - 3.1 Licensed Construction Supervisor/Specialty License: f-><<Cxei l ,Sp✓1 License Number-09-5 Company Name/Contractor Name: -t4p Address: -A �7c /, -2- Expiration Date: Signatu ` Telephone: JVol - - QQ 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: - �-SECTI©CV;`4 WORKER;"E-,CQMPENSi41'ON aNSU'FtA,tdGE AF'F1DA�/IT{MGL c,152 §�5) - ;-- 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 SEGTtfJIV 5' DESGRI'RTI01V OF PRQPOSEQ�NVQRK,(Check`alt appltcab[e) , .. t y ` � ' ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ W� 0000dstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding [5 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: FA Single Family: No. of Bedrooms No. of Baths Twe, 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 (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 ❑ Hot Water: Gas Electric Fuel Oil Other SECTION 6_, ' '1MATEQ COI tSTRIJGTIiD�i UOST , Item Estimated Cost ($) to be completed by permit atpplicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total =(1+2+3+4) / s SECTION 7A1 TION (fo be aompiete, l when;owner's'agent or coh1ractor:app ies` for --bull l ling pe`rm,tt) (Please Print) 1, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. See 'A&C tgeJ c6eH rac-* Signature of Owner Date SECTION 713 -OWNER/AUTHORIZED AGW,DECLARATION, I, Z (' c an ]�i6 A is n ✓1 as Owner/Authorized Agent hereby declare that the statementts and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains an penalties'of perjury. /I Signature of Owner/Authorized Agent Date z777777SECTION 8 OFFfE/(NSPEC70R`Sy1�tOTES _..- , _. Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ I Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued to: " t 14/6-5 C.` 14 de S7/ticZC/ra REST ENTI ® Phased Approval (R106.3.3) Board of Health: Signature: Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: ' Brief description of work being performed: /SECTIQP! t_ ITE;(NP,ORMAT(ON , 1.1 Property Address: 1.2 Assessors Map & Lot Number:: Contact Person:Map W— Lot Phone Number: AD/ -�,� � - �' D C) 1.3 Historical District ❑ Yes; ❑ No 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ Municipal ❑ Municipal ❑ Altering more than 25% perr,side of building ❑ Private Well ❑ On Site Disposal System Has application been submitted to tthe Historic Commission? ❑ Yes ❑ No [bate: