BP-651001-1 Annrn,iol in Dori IQ-7PO ('AIYQ r994 4Q1
1.1 Property Address: 3K *7 &2c k 7 y.l , »Q�1°� 1.2 Assessor ap Lot Num
Lot Area (sf.) Frontage Map o -
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard Year Built
Rear Yard
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission?
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System ❑ Yes ❑ No Dater
Page 4
CONSTRUCTION
LJ SITE PLAN El ENERGY REPORT
Page 1
C
P
Y
F
L
i
C
E
N
C
E
(S)
ES In 719711
,
a
SECTfOi�9 2 = PROPFRTY 9,A NE
� � � --la �E�
..HI" IAU € ORIv D , G7NT . '.
2.1 Owner Record:
1 � 46l.
Name (print)
Con ac Address Phone Number
2.2 Author' ed Agen r
�� /0
r4 cL��:�„
G e
Nam�V'
(p )
Contact Address Phone Number
.:SECTjC3f .3 'CONSTRUCTION
SERVICES
3.1 Licens Construction Supervi cialty License:
License Number:
Company Name/Contractor Name: CS
Address:3
Expiration Dater
o2.069O1'3
Sign re: lephone: - oZ —BSO�
3.2 Registered Home Improvement Contractor: / o1 < 5;�`
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? 2- es ❑ No
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes Go to Secti�n 3.3
Company Name/Contractor Name:
Registration Number (if none, state "none"):
/
%
Address: -7-HL�
Signature: Telephone:
Expiration Date: Z2-2
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 FlIace - Room 1301, Boston, MA 02108, 617-727-8598
❑ 1 am a Homeowner performing all the work mys lf.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility 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
6108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building.
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 Homeowne
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 whic
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 tha
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
rage z
Page 3