BP-54822Inspector's Signature:
Date:
Zoning Review: Signature: Date: 4f�_
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: T Date:
Conservation Commission: Signature: Date:
Other: Signature: / Date:
� r
Brief description of work being performed: IL / 41;"
j
1.1 Property Address: 7 ,t, / J1 /ji f V eefE ".,j
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Feet:
1.2 Assessors Map & Lot Number:
Map _ Lot I� -
1.3 Historical District ❑ Yes ❑ No
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.4 Water Supply (MGVrdAvate
'): 1.5 Sewage Disposal 7(01n
rr_
❑ Municipal Well ❑ Municipal Site Disposal System
❑ CONSTRUCTION PLANS ❑ SITE PLAN
❑ ENERGY REPORT.
RESIDENTIAL NOTICE TO LICENSED CONTRACTORS The Buildin Code rovides in the Ru les and Re ulationsse 4i n thatan NA C t t'
L-wGlwGu %lvrrsuucuvn oupervrsor. Wt License Number.
Address: / / s , Expiration Date:
i Signature: C{ Telephone: Q a ' - 3- aZ�/09
1
' 3.2 Registered Home Improvement Contractor: , Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? � Yes ❑ No
I If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name: p Registration Number (if none, state "none"):
50
Address: /
A-7 ZAP
Signature: Telephone: 1? 9b%-g (,jl Expiration Date: 7 /b
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
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Dater
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 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:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
g p g to y cense ons ruc ror
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5:2.15)
"SECTION`4,_.WORKER'S COMPENSATION INSURANCE AFFIDAVIT,,(MGL`c 152§
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ; XYes ❑ No
�SECTION'5 � DESCRIPTION.OF PROPOSED'WORK-(Checkall:applicable)
❑ Deck O Pool Jk Repairs ❑ Afteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other,
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows Doors (Specify 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
❑ Air conditioning (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed work: L
T
Item
1. Building
2 Electrical
Cost M to be
v v
3. Plumbing Roar)+� ►-
4. Mechanical (HVAC) -
5. Total = (1 + 2 + 3 + 4) /O. 0 ®�--
��° L� '�� � �� � SECTION'7A .OWNERAU7'H(3RIZATION � �� `� `•ham
. "` _',�� - _- :(tobe completedi when owner's"agent.or contractor appliesfo� tiuildin 'ermt �- y
(Plea a Print)
1, �a-f r•, n G r -Ft�I(f�l as Owner of the subject property hereby authorize 6)" f��iPJjC3 '�
to act on my behalf, in all matters relative to work authorized by this building permit application.
-� o"
Sign ture of Owner Date
'.,.1 .... , >:.. .. .._ i;tG,ttUN 7t3-UWN,CRIALITHpRIZEDAGENT DECLARATIpN
11,0Y jPJe6qq,1)% as der/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
lD//l
Signature off/Autho ized Agent Date