PermitPG3SECTION 5- DESCRIPTION OF PROPOSED WORK check all applicable)
New House ❑
Addition
Replacement Windows Alteration(s) Roofing
Or Doors i
Accessory Bldg. ❑
Demolition
New Signs [0] Decks Siding!KJ Other {0]
Brief Description of Proposed., g�
Work: Y� 'C� r13� -0cj� (
Alteration of existing bedroom Yes No Adding new bedroom_ Yes No
Attached Narrative Renovating unfinished basement Yes No 7 �
Plans Attached Roll - Sheet C
sa. if New house and or. addition to existing housingicomplete the following:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: G umber of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new constru)ction/_ Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. - &IZA Masscheck Energy Compliance form attached? /Y
h. Type of construction
i. Is construction within 100 ft. of wetlands? YesNo. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade' " f 4—
a�
k. Will building conform to the Building and Zoning regulations? X Yes No.
I. Septic Tank City Sewer X Pdvate well City water Supply____
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, } l~ �� C. / G ► C er on as Owner of the subject
property
hereby authorize
to act on my behalf, all ft relative to work authorized by this building permit application.
e1
sSignature wn D
as Owner]Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
{
Print Name
Signature of Owrf&/Agent Date