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FORM U LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT kqVk — %4 fyyuIGS PHONE(° - '�f Ck
LOCATION: Assessor's Map Number PARCEL Li6,50
SUBDIVISION LOT(S) q B
STREET UL,� �� -ka aA
v1 ST. NUMBER
************************************OFFICIAL USE ONLY***********************************
REC MENDATION F TOWN AGENTS:
CONSERVATION ADMINI RATOR DATE APPROVED A90103
DATE REJECTED
COMMENTS JVP File, �C,(er► OLNl- 965 ° (PM 10SA QLAS,cL 106.i b-Or-
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH DATE APPROVED d
DATE REJECTED
COMMENTS
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9\97 jm
SECTION 4-WORKERS COMPENSATION(NLG.L. C 152 § 25c(6)
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 Yes......X No.......❑
SECTION 5 Descri tion of Proposed Work(check all applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFFICIAL 1JSE ONLY
Completed b ern
applicant
1. Building (a)
Building Permit Fee
G1 J
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a) x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 'eA vdF as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf,in all matters rclative-to p
rk authorized by this building permit application.
Signature of O r Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
G6�
Print Name
Si ature of / nt Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1ST 2ND 3
SPAN
DIIv1ENSIONS OF SILLS
DM ENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CH NEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE