BP-41575•RESIDENTIAL
2005
;,SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2- 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals(see project review worksheet):
Date:
5. DENIED (see project review
worksheet): Date:
6. HOLD
reason:
Date:
7. HOLD subject to Zoning Board of Appeals action:
Date:
8. Comments:
9. Inspector's Signature:
te:!®
s . SECTI 9 AP LIC NOTIFICAT ON -..
_
Applicant inform o ate: U Time:
Clerk:
Comments: V_�k
SECTION 10— OFFICEIINSPECTOR'S NOTES . • ,,, ,
Total Permit Fee:
Less Application Fee: $ 25.00
Remaining Balance: $ ' 670
TOTAL FEE:VK,6d . 00 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To•��+� `�� C7_.r_c_/1
6'
czQ-
. SECTIQN11= Ar&ffIONAI; COMMENTS/SKETCHES
RESIDENTIAL 1 1 2005
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
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2005 RESIDENTIAL
2005
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AUTHORIZ
2.1 Owner of Record:
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Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
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Name (print)
Contact Address Phone Num r
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i
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
Address
Signature Telephone
Expiration Date
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
owners Name (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
all be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
fr structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
Supervisors.
Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For the purposes of this section only, a "Homeowner" is defined as follows: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than
one home in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature: 'x .
'Your` signature carries certain responsibilities, include g but not necessarily limited to, general liability
❑ new construction* ❑ addition
(energy report required) (energy report rewired)
deck ❑ pool ❑ accessory bldg.
(shed/garage)
* If new construction, please complete the following:
Single Family: no. of bedrooms
❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
fireplace
❑ replacement window/door ❑ other ❑ demolition
no. of windows_ doors_ (specify below): (specify below):
no. of baths
Two Family: no. of bedrooms unit 1 no. of baths unit 1
no. of bedrooms unit 2 no. of baths unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):_
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
Item
5. Total = (1 + 2 + 3 + 4)
Estimated Cost ($) to be completed by permit applicant
* Estimated Total G S
(please rint) �� S�i�.�l,,_r
I �� ,%F(�, as Owner of the subject property hereby authorize
to act on my half, in a11A afters re #iv o wo authorized by this building permit application.
Signatur of Owner
..........
information
' form
�f�°��%` ' �//%, as Owner/Authorized Agent hereby declare that the statements and 1n
the for application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of Perjury.
.,it
Signature of Owner/Authorized Agent
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Date
Rev. June 26, 2003
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