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Authorized
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Agent:
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Name (print) Contact Address Phone Number
1
1.
s Ec TtoN 3. c. c..
T o �N RU S 1 � R ESQ
3. 1 Licensed Construction Supervisor/Specialty License: _ _ _ License Number:,,
Company Name/Contractor Name:
Ad'dress:
S io nature: - ---=- L
TeIephone: � � ► .�
4
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Item
Estimated Cost to be completed by permit aPP lican t
1.
Building
r
2.
Electrical
-
3.
Plumbing
4.
Mechanical (HVAC)
5.
Total =0+2+'3+4)
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��ECT _OWNER H R�l •T' Z. t� Q
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(Please
Print)
-V'e-.
i,
as Owner of the subject property hereby authorize
S:��
to
act o m e half � all
Y r I matters
relative o work u I t authorized b this bui
lding ildin permit
mta application.
Y 9 P PP n.
Signature'of Owner
uaie
. ... .. . ..:. . :-.
�AGE�
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LARA o-.. •.:° Q NER�AU HO�IZEDEx Expiration Date .....
C-N \-Ml Mae
3.2 Homeowner Exemption - One & Two Family Only Section 114.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exviception: 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
enc = ges a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
Fcr 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:
_ ....... _WORKER'S...._.. ..
ENSAT . _
�-AAN EFFfiDAVR0 :. T. I�iGI�••:c- 5 - �- .
Wo-ker's Compensation
Insurance Affidavit must be completed and submitted with
this application. Failure
to "de this
affdavit will result in the
denial of the issuance of the building permit. Signed
Affidavit Attached:
res
❑ No
'SECTION � -DESCRIPTION OF PRClPOSED WORK (Check all applicable]
Rl Deck ❑Pool /Repairs ❑Alteration ❑ Chimney/Fireplace
❑ WoodstovelPellet Stove
10 New Construction* ❑Accessory Bldg. ❑Roofing/Siding ❑Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition
❑ Replacement
window/door
❑Demolition
(Energy report required)
No. of windows
Doors
(Specify below)
*If new construction, please complete the following:
Since 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
❑ Fu. pace (hot air) - fuel gas (natural or propane), fuel oil, eledtricity, other (specify):
❑ Bovler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HV,,kC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air-conditioning -- (separate unit)
❑ None of the above to be provided
0 Hod Water: Gas Electric Fuel Oil Other
as Authorized Agent hereby declare that the statements and infrormation
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 ofVn9rr/Authorized Ilent
W_.__
Other $Amount $
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
NOW
Date
• A ,o lob
Permit
m t issued to: ./�
l � �
i•
WOW-
. . ........
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TION♦ . '•DESCRIPTION OF WORK B E fNG PERFORM.:....::.:..:....:
,
abris RtMnOv
rize-or MG' '.40
,
I . A 4- 21,,. �
I kl,
of 410MEW low
W
El Phased Approval (R106.3.3)
$25.00 APPLICATION FEE IS N014T BTaFIIND.4,BLlE
& NON-TRAN91Vjk- lwkii�p
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:�-E TI ON
T` INFO
0
1.1 Property Address:llb1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map Lot -
Reguired
Provided
�y
Front Yard 1.3 Historical District ❑ Yes l3 No)
Side Yard Year Built
Rear Yard
1.4 Water Supply (MGL
c40 s54):
1.5 Sewage
Disposal System:
❑ Municipal ❑Private
Well
1 ❑Municipal
❑ On Site Disposal System
❑ Altering more than 25% per side of builcJing
Has application been submi to the Historic TCom mission?
❑ Yes o Date:
iRevised 10/11
CI CONSTRUCTIOIrm PLANS � SITE PL,4N ❑ Ef�ERGY R�;PORT
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