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BP-145442000 Ml RESIDENTIAL o FOUNDATION ONLY $25.00 APPLICATION FEE IS NONREFUNDABLE & NON TRANSFERABLE 2000 Rev. lanuary 20.2000 ,,.%........ ;,.�F ....��Hi.�„a.,.. rP� naoP u..., ia. —,,1n )nnn RESIDENTIAL 17nnn ........:..:........ . ::;.:::::.:.::.:::.:.......;::;:.::.::.;......::.;:.:.::::.:.. ;:..'>`? :>:.. <: aeTION 2,-.) li(;T'Ellki€ i'.b4 EltStilPl: itTli itt of AGENT <:: 2.1 Owner of Record: ...................::. UtCI •!' �i/itiollt� Yrt7Gln'7 a�% Q' Py Name (print) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address 0 a�'J` Phone Number :::..::;::>::<,.a:.;...... >::'> Li :»::CQ�SER T>CTif3N:SER�i :. 3.1 Licensed Construction Supervisor: e r 1'S Not Applicable ❑ Licensed Construction Supervisor License Number CS 694 Y77 Address 3 .-- e " J ()AM6 Expiration Date f © YQ1 , Signature P.Telephone YQ� — �� 3.2 Registered Ho u Improv4 j nt Contractor: Not Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR-6)? es ❑ no If no, go to text section! Are you claiming exemption from the requirement? ❑ yes Gino If yes, submit the required affidavit! Company Name �� t re?r7r0 FS • Registration Number (if none, state "none") Address -lCt Signature t I Telephone y��—�LQ� Expiration Date (� f 3.3 For Resident. al Remod 1 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 shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings or 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 dwelline, 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: Your signature carries certain responsibilities, including but not necessarily limited to, general liability RESIDENTIAL 2000 NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction I Supervisor. whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affid vit I will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes E?, no 6t7 p� , e ❑ new construction* E3"addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove (energy report re quired) uired ( (en re port ort required) P 9 ) fireplace p ce ❑ deck ❑ pool acce Bldg. ❑ replacement window/door ❑ other ❑ demolition (shed. Darage no. of windows doors_ (specify below): (speciA, below): * If new construction, please complete the following: Single Family: no. of bedrooms 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: I Item I Estimated Cost ($) to be completed by permit applicant 5. Total = (1 + 2 + 3 + 4) 1 * Estimated Total $ 44 ;fin%7 W (pl a print) 00,071P n mi'r r ^ �rytzw tF7, , as Owner of the subject property hereby authorize ,. to ton my be alf, in all M4tters relative to work authorized by this building permit application. Sign4fure of Owner Date 1,Vf $yrrr. on the forego' b Signed un er the Signature o Owr k I?d 717t`6 s , as Owner/Authorized Agent hereby declare that the statements and information \lication are true and accurate, to the best of my knowledge and belief. A a t. c:\wpwin\forms\bldgapp.res Page 2 Rev. January 20. 2000 c'\wnwin\fnrt Q\hlrioann rrc D--