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FORM U — LOT RELEASE FORM & cP f
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/,i cv/Z`7`" .T/'f�.E6//-.Z,W. s 4�1 PHONE
LOCATION: Assessor's Map Number.
SUBDIVISION
PARCEL
LOT (S)
STREET! 5 ST. NUMBER
*******OFFICIAL USE ONLY*********************************
R
CONSERVATION
TOWN PLANNER
COMMENTS
FOOD
SEP-_TI'd S R -H
COMMENTS
TH
:TOWN AGENTS:
TOR D �E-•AP D
DATE REJECTED ��. ,
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWERAVATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
Revised 9197 jm
DATE
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SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will
in the denial of the issuance of the building permit
Signed affidavit Attached Yes ....... ❑ No ....... ❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Existing Building [IRepair(s) ❑ Alterations(s) ElAddition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
101410v
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS 1
Item Estimated Cost (Dollar) to be
Co leted by permit applicant
OFFICIALPSE.ONLY
1. Building(
a)
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (8) 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
as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, 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
Print Name
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 ST 2 ND 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
'li I 1 ISi
# of
Proposal Submitted To: Job Name Job #
� r t
Address Job Location
F
Date Dat of Plans
AI C` / /
Phone # Fax # Architect
We propose hereby to furnish material and labor — complete in accordance
with payments to be made as follows: _
Any alteration or deviation from above specifications involving extra costs will be
executed only upon written order. and will become an extra charge over and
above the estimate. All agreements contingent upon strikes, accidents. or delays
beyond our control.
the above specifications for the sum of:
i
Dollars
Respectfully
submitted. / '4
Note — this proposal may be withdrawn byif not acc pted within _ days.
Rcceptance of I)ropozai
The above prices, specifications and conditions are satisfactory and are
Signature !�
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
Date of Acceotance __ f = !i ` Sinnati tra
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