the TOWN of HARRISVILLE in the Monadnock Region of New Hampshire incorporated in 1870 Town Offices 705 Chesham Road, Harrisville, NH 03450 603-827-3431 voice Building Permit Application Property Owner Owner’s Name Phone / email Mailing Address Applicant’s Name (if different than Owner) Mailing Address Phone / email Permit for work on property located at Property tax map ID (map and lot) Property Address Contractors (list all applicable) name and telephone General Contractor / Builder Plumber Electrician Site Contractor Nature of Building Improvements (check ALL that apply) Residential Commercial New Construction Additions Interior Remodeling Deck Agricultural Repairs Garage or Shed Other (describe) Special Conditions or Notes: . form last updated: April 24, 2015 page 1 of 2 General Description of the Work: (to be accompanied by plans and elevations drawn to scale) Describe the nature of new work or change in use. If the use of the building is being changed, describe existing and new uses. All new structure and additions must include an accurate plot plan with proposed setbacks shown. For residences list the number of bedrooms. Does Proposed Work meet Zoning Setbacks? see Zoning Ordinances) Does Proposed Work meet Shoreland Conservation District Setbacks? see Zoning Ordinances) Does Proposed Work involve construction on Steep Slopes? (see Zoning Ordinances) Provide setback dimensions (front, back, left side, right side) Provide setback dimensions (front, back, left side, right side) Does Proposed Work have a valid NH DES septic permit? Does Proposed Work fall within Special Flood Hazard Area? Applicant Certification Estimated Cost of Construction I hereby certify that the information provided is true and correct to the best of my knowledge. No changes to the information provided shall be made without approval of the Code Enforcement Officer. Construction activity will not begin until the Building Permit is issued. I grant the Code Enforcement Officer the right to enter the premises or buildings at reasonable times during the construction. All work will be performed in accordance with the applicable laws and Fire and Building Codes of the State of New Hampshire. I further acknowledge that the proposed structure will not be occupied or utilized until a Certificate of Occupancy has been issued. Printed name . Signature of Applicant and date page 2 of 2