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�gineenng Dept. (3rd floor) Map ` Parcel ' _Il� " Permit#
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House#.' 'j�Gj Date Issued
Board of Health(3rd floor)(8:15 9:30/1:00-4:30) Fee'
Conservation Office(4th floor)(8:30- 9:30/1:00-%2:00)
Planning Dept.(1st floor/School Admin. Bldg.) THE
Definitive Plan Approved by Planning Board 19
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Building PermitZAplication
Project Street Address
Village
Owner / t Address
Telephone
Permit Request
First Floor square feet Second Floor square feet
Construction Type "
Estimated Project Cost $ 01
Zoning District Flood Plain Water Protection
Lot Size Grandfathered `❑Yes ❑No
Dwelling Type: Single Family ❑' Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes '❑No On Old King's Highway ❑Yes ❑No
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half: Existing New
No.of Bedrooms: Existing New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: ❑Gas ❑,Oil ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
Builder Information
Name Telephone Number 3 G / 7 Z
Address �Z License# 0 o Y :2 7 C
' Home Improvement Contractor# /G
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
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FOR OFFICIAL USE ONLY
PERMIT NO. — f
DATE ISSUED. "
MAP/PARCEL NO.
11 • t
ADDRESS - VILLAGE
. OWNER i t i >^ _ • .,� � � - ,
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION -'
FIREPLACE —
ELECTRICAL: ROUGH FINAL ,
y
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL r
FINAL BUILDING
a
DATE CLOSED OUT
ASSOCIATION PLAN NO. :