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Item
Estimated
Cost
to be
completed by permit applicant
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21 Owner Record:
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Name (print}
Contact Address Phone Number
2.2-,�A, ut.'norized Ageofl, I
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Name (Print) Contact Address Phone Number
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License Number lot
3.1 Licensed Construction Supervisor/Specialty License.
Cornpar..y Name/Contractor Name /6 ewx u,
Add
Expiration Date:
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Signatui ... m- j
8.2 Homeowner/Exempation - One & Two Family Only Section 11 O.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exceptiori: 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 -r_ 1-person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For the prirposes 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
6 o constructs more than
there is, or.", ;s intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures' A person wh
one home rn a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
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Workers 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: rl Yes 0 No
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0 Deck- ❑0 Pool 0 Re pairs 0 Alteration 0 Chimne y/Fire place [30oodstove/Pellet Stove
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0 New"Construction* 0 Accessory Bldg. D Addition 0 Roofing/Siding 11 Replacement window/door
tEnertzly report required) (Shed/Garage) (Energy report required) No. of windows Doors.
0 DEMOLITION (specify):
Locate on of debris removal (per MGL C.40 Sec 54): 11 Dumpster on site 0 Dumpster On Street
Facilit'l Name: Location:
If new construction, please complete the following:
Single FE-Mily: No. of Bedrooms No. of Baths
Two Fa rf.,-Ily: No of Bedrooms Unit 1 No. of Baths Unit I
No of Bedrooms Unit 2 No. of Baths Unit 2
0 Furnace. (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
0 Boiler (rleating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
0 HVAC �oornbined unit) - primary fuel, natural gas, propane, electricity, other (specify):
0 Air conr--'�itioning - (separate unit)
0 None c'the abov,:,- 9,vi
0 Hot W-C.-...r: AV Electric Fuel Oil Other
1. Building
12. Electrical
3. Plumbing
4. Mechanical (HVAC}
5. Total= (1 +2+3 +4)
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(Please print
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as Owner of the subject property hereby authorize
to a6tton my behalf, in all matters relative to work authorized by this building permit application.1�'
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Sig 'ature ofo-4i.er Date
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as Owner/Authorized Agent hereby declare that the statements and informatl'ion
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed and the pains and penalties of lUry.
Date
i nature ofAw66�/Ad6orized(8g4t
19
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Total Permit Fee: $
11
Less Application Fee: $25.00
Other $Amount $
Gross
Area -
New Construction
total sq. ft.
Gross
Area -
Alteration total
sq.
ft.
Permit Issued to: ��i '� ��� �� � �- �
rz-041
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P A,39
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Remaining Balance: $ -cll� 11 �-
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