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BP-86881-- SECT,ION 6-ESTIMATEa CONSTt IiCTtCDN COST RESIDEDTIAE SECTIOIrf 2 - PFtE3PERTY©VYNECtSHIt�IAtJTHaRtZEQ AGE�tT 2.1 Owner Record: _ /9 Al 70/it/Oocl g!o b fir, KA Ka(; <���s S �! ��rfi `M6 ' y �� Dom, �� > 7-3 GJ Name (print) Contact Address Phone Number 2.2 Authorized ,Agent: �/ r � i l nniso 11 ZS�� (A�k ul_S /, I' xc/ t -T YcZ y2&- q?0Q Name (Print) Contact Add ess Phone Number - = _ - , SBCTCONt3COIefSTRUGTIdfV S�R1tCEES� .� - 3.1 Licensed Construction Supervisor/Specialty License: License Number` p Company Name/Contractor Name: st y a u S Address: A- 'd4l Expiration Date: r Signatureff-N,Telephone: 3.2 Homeowner Exemption - One & Two Family Only SeFtion I IG.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: _ _ SECT[Ol(f4 ti{FORMCsL'c15Z5 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: Pryes ❑ No = � �'1�IGNi:S _ EIESGRtPTfOt� DF Pi�t3lrQ�l� V�ORK_�tbeaCC�ilFapp�cabtr�� �" � = � :: ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ['Replacement window/door (Energy repot required) (Shed/Garage) (Energy report required) No. of windows 4-4 Doors _ ❑ DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street Facility Name. Location: *If new construc",ion, 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 (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 abave to be provided 11 Hot Water: Gas Electric Fuel Oil Other Item Estimated Cost ($) to be completed by permit applicant 1. Building r- 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1+2+3+4) 'g SECTC63tst_7A'0WNEl-LA T. EIRIZAT(O[� `(fo be .�a�nnpfeted when owner's agent or circa appE=xes for hiiifdtn perri�itj . (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. Signature of Owner Date _ _' SECTtCtV7 - QINNEt7lAUTH®RtZEQ ,tfVT C?ECtFT1aN _ SepV1 as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pain and penalties of perjury. Signatur Own uth ized Agent Date ss Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ J Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. --ft. Permit Issued to:i'� d EGTCQCiE DESGf3lPTf[1�[ �FE)i3FC FFIFZIID . = ._ - _..7-77-777 M .5-4? r"10 /Gec All P "fi i 'l-� 4&tv S ,i1 i7 ,S'firtic r� RESIDENTIAL ❑ Phased Ap proval (R106.3.3) -c2 —00 APPLICATION FEE IS NON BE-1FliND LtE � NON-T?f�A.tYSIFERABIE _ Se 110 1, SITE-tI�EQR1Vf�4TIEiN = 1.1 Property Address: /8 60-//4�8 oW (� 1.2 Assessors Map & Lgt Number: Contact Person:Map Lot _ Phone Number: C I — J_ Z 9— If O 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% per side of builcaing ❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic; (Commission ? ❑ Yes ❑ No Date: Revised 5 /13 -_[:]_,CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY R. PORT _- - R.