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• License Number:
3.1 Licensed Construction Supervisor/Specialty License.
an Name/Contractor Name.
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S nature: Telephone,.
3.2 P y Y
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
er►zages 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 helshe resides or intends to reside, on which
� - structures: A person who constructs more than
the-! e is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm
orre home in a
two-year period shall not be considered a Homeowner.
Y
If you are applyin rthis ti S'V si n below:
f ter"
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,n s Compensation Insurance Affidavit must be corn feted and submitted with this application. Failure to provide this
v`� orker' p P .
�-~ t in the denial of the issuance of the building ermit. Signed Affidavit Attached: ❑ Yes ❑ No
ar �Idavit will resin g p
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❑ Chimney/Fireplace0 Deck ❑ Pooi ❑Repairs ❑ Alteration ❑ Woodstove/Pellet Stove
J
❑ Roofing/Siding❑ Replacement window/door
0 New Construction*❑ Accessory Bldg. ❑ Addition
e uired(Shed/Garage)re ort re uired) No. of windows Doors -(Energy report r q } P q
0 DEMOLITION (specify):
Location 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):
G Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): -
❑ •HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
0 :Air conditioning - (separate urlit) -
l! None of the abov Rv d '
ri .L4nf Mlnfor• rl- . _ . - --- - - PIPr.trir Fuel Oil Other
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Item
Estimated Cost ($} to be completed by permit applicanit
1. Building
•
2. Electrical - -
3. Plumbing •
4. Mechanical (FIVAC) _
.Total= 1+2+3+4) � _
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l , as Owner of the subject property hereby authorize
relative to work authorized b this building permit application.
a tters ref 9 P P
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Signature of Owner Date
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as Owner/Authorized Agent hereby declare that the statements and inf' rmation
Xonefore oin a lication are true and accurate, to the best of my knowledge and belief.
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Signature of Owner/Authorized Agent Date
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Less Application Fee: $25.00 Remaining Balance: $
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Gross Area - Alteration total sq. ft.
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