HomeMy WebLinkAboutForm U - lot release form 6/4/02 above ground pool - Miscellaneous - 45 TUCKER FARM ROAD 8/2/2019 i
FORM - U - LOT RELEASE FORM
INSTRUCTIONS: .This form is used to verify that all-necessary
rify approval permits'from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from-compliance with any applicable requirements.
ISOM mommummonam am MEN ENE MENNEN a mono a No oil ME ME am No sun ME am won a a
APPLICANT W�V►' a�l�l'U�l PHONES
ASSESSORS MAP NUMBER LOT NUMBER
SUBDIVISION LOT NUMBER
STREET 5 "44m, Fowm STREET NUMBER
...-...............................................................................
OFFICIAL USE ONLY
.OEM.........noun.......WON mono ENO WINE.NNE ONE...won..MIN man some news.............:
RECOMMENDATIONS OF TOWN AGENTS
...............MEN.........MEN mains...MESON.......■r.............r...r.a......■
C---CONSERVATI
�NSE ONADMINIS DATE APPROVED
TRATOR
DATE REJECTED
COMN EN TS
DATE APPROVED
TOWN PLANNER
DATE REJECTED
COh04ENTS
DATE APPROVED
FOOD INSPEEfCTOR--BEGA'LTH DATE REJECTED' /l
DATE APPROVED v
S" EPTIC ECTOR—HEALTH
DATE REJECTED
COMMENTS 0 AhCCU L z` r ff
d s1 ZLs 10,
PUBLIC WORKS—SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT .
DATE APPROVED
FIRE DEPARTNII;TTT
DATE REJECTED
CONDAENTS
RECEIVED BY BUILDING INSPECTOR DATE
i
a
SECTION 4-WORKERS COMPENSATION(M:G:L. C 152 § 25c(6) -71
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will!result
in the ddnial of the issuance of the building permit..
r
Signed affidavit Attached Yes....:..0 No.......0
'SECTION 5'-Descri `tion of Pro o`sed Work &eckall a lieable
New Construction ❑ 'Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
Add.60 of 18 6'- alx t ctownd
SECTION 6 ESTIMATED.CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be
Com leted by perrmapplicant
1. Building (a) Building Permit Fee
060 , 00 Multiplier
1. 2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(i)x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total•(1+2+3+4+5)' Q . 00 Check Number
SECTION 7a-OWNER AUTHORIZATION TO BE COMPLETED WHEN'
OWNERS AGENT OR CONTRACTOR:APPLIES.FOR BUILDING PERMIT 7T
arvnq�
I, ...............
,as Owner/Authorized Agent of subject property
Hereby au rize to act on
My be t- 1 Il m tters re tiye�. work orized by this building permit application.
Signature of Owner V` Date
SECTION 7b OWN - 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
Si ature of Owner/A ent" Date
NINE Is pill
NO:OF-STORIES SIZE'
BASEMENT OR SLAB ND
RD
SIZE OF FLOOR TIMBERS
1 sr 2 3
SPAN
DIMENSIONS OF SILLS
DDAENSION&OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF ClluvviNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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