BP-81340RESIDENTIAL
SECTION =PI OPERTY WRI(ERSHIPIAUI'NORI
Et),A ENT,
2.1 Owner Record:
j�� f d ill � • �/�1�'�.
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
MLA
Name (print)
Contact Address Phone Number
- SECTION 3VC6NSTRUCTI0N SERVICES
3.1 Licensed Construction Supervisor/Specialty License:
License Number: 6V 0�o
Company Name/Contractor Name: &PV77,oqf� VIWJW 5 Q/�"
Address: %^i f
Expiration Date:
Signature: ,��c fl'f,• 1`'...�`%' 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, cr 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:
., ' �EC�CON 4 �IVORK_ER'�,COMPENSi4TfbN IIVSl1Rf�NCE'�iFFIt3AVIT-(iV1Gl_.c;152 § 25} _, . 2. '= � -�-
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit will result In the dental of the issuance of the building permit. Signed Affidavit Attached: ❑Yes ❑ No
SECTI{IN _5, , E$GRIPTiON;L}F.:PRUPOSED.WORK (Checktiah aj�placahlsj ,. -.. a'
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition :_ ; Roofing/Siding Replacement window/door
XNo.
(Energy report required) (Shed/Garage) (Energy report required) of windows Doors
❑ DEMOLITION (specify):
Locat r,on of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street
Facility Name: Location:
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler ('treating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of, the above to be provided
❑ Hot Water. Gas Electric Fuel Oil Other
SECT(Oh16= ESTIIV_IATED:`CONSTRUCT(ON COST
Estimated st to be completed b permit a lice
Item Co ($) P Y P PP .ant
as Owner/Authorized Agent hereby declare that the statements and iinformation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed un th ains an nalties of per' ry.
1,4�
,
i Si ' ature of Owner/Aut orized Agent Date
Less Application Fee. $25.00 Remaining Balance: T
Total Permit Fee: $ J
Other $ Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
RESIBENTIA1 ® Phased Approval (R106.3.3) E
$25.00 APPEICATION FEE IS NON HE-FUNIBABLE �
= � SECTION 1,> SITE IN�ORMAT�QN .';:"
1.1 Property Address: MJ 7 0A)i b rl 1.2 Assessors Map & Lot Number:
Contact Person: g � -507 1 Map 73 Lot - - 3
Phone Number:
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 buildings
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Corrnmission?
❑ Yes ❑ No Date:
Ke;,Vis I
CONSTRUCTION PLANS SITE PLAN ENERGY REP,