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BP-90389RESIDEKTI L _ SEC.710N;? `= Pi2L�PRTY'WIVIERSHIPfAIJl HORIZED ANENT 2.1 Owner,'Record: 4 4A1-t1 V/ram Na e (pri t) Contact Address Phone Number 2.2 Authorized Agent: c gof Name (print) Contact Address Phone Number UIdST4it1CT10N.�ERVICES _ - 3.1 Licensed Construction Supervisor/Specialty License: 6 .-q D License Number: Company Name/Contractor Name: e lrl %' - Address: d Ala, ,4 7-7 3 Expiration Date: % Signature: Telephone:p 3.2 Homeo r Exempt - 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 in+tended 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: _ , . ,t =, ,SECTION �, iNt�RK£R,'�COMPENSATIj.OhI iNS�IRARt�E AFFID�#�1T,((�IGL�p 't5� §=25� , _ - = 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 - �: � SECTION 5 DESCRt1l�Tl�3N,QF PR(�PtySED:W�iR� �Gheck a1f applicable} _ y' ; _ _ ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition Roofing/Siding G�Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. ofwindows/j9 Doors ❑ DEMOLITION (specify):o Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpsteron site ❑ Dumpster On Street Facility Name: /V /3- yv/ 4-�F 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 (hea'3ng) - fuel gas (natural or propane), fuel oil, electricity, other (specify): ❑ HVAC (cordbined unit) -primary fuel, natural gas, propane, electricity, other (specify): ❑ Air conditioning - (separate unit) ❑ None of the above- - vA__d 0 Hot Water: Gall*__ — - Electric Fuel Oil Other r SEiiON 6 .;ESTINI;iECk©NSTRUCTIO['Cf�ST Item Estimated Cost ($} to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total 0 +2+3+4) `� -QO, 042 SEGTfON 7A ®;NCR AUTHbt24iAT1aN = .;- _ � {to:be ca�spletet�n+Fien�owt�er`s agent�or coritractorapp[res�-'tor buildrreg permlf� -= (Please Print) 1, A,10-Ai le , as Owner of the subject property hereby authorize Ate to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of O er Date -T SECTION 7B OWNER/AIJT.FfORiZED,AGENT OECL:A""RATIa3hi 1, as Owner/Authorized Agent hereby declare that the statements and informmtion on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Signature of Owner/Authorized Agent Date SfCTCON 8 tF1�FJlNf'ETOR"SNOTE 7� 7� Less Application Fee: $25.00 Remaining Balance: $. Total Permit Fee: $ Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. i Permit Issued to: y _EGTION 9 [ESI#FTIDi�t OF1€OtE�13Et�G PE?OIME , i RESIDENTIAL ❑ Phased Approval (R106.3.3) $25.00 APPLICATION FEE IS NON HE-FUNBABLE lY®N.TBANSFER LE OeA7� �6111 I