BP-64344F r��_r-C —� `'t 1r71 R
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1. Date plan reviewed: CC",..P 2 3 200
2. DENZED (see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: Date: SEP 2 3 2011
Applicant informed of above: Date: Time: Clerk:
Comments:
s�.
^� Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee:
Other $ Amount $
Cl Aooroval in Part (Psr 780, UvIR.5111.13)
Page 4
CONSTRUCT RUB tzO � PEAKS Do SNITELAEe � g e s
Page 1
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Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
2.1 Owner Record: affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
Name ( rint) Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
SE -- Tlbl 3 r f3N TRU_T1ON:S�R`y1r_ES x t
.m
3.1 Licensed Construction Supervisor/Specialty License : License Nur4 be� �b (at
Company Name/Contractor Name: V, L ftc/C
Address: �l�t �aUVest,,ezrp.27 F cl Expiration Date:
® Signatur : Telephone: �� �3/— / 3
P 3.2 Registere Home mprovement Contractor: Not Applicable(❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? eyes ❑ No
..a
F Are you claming exemption from the requirements? ❑ Yes flNo
A If Yes, Go to Section 3.3
Company Name/Contractor Name: p ,2 j, r /, ' // Registration Number (if none, state "none"):
Address:? VV vi7- 4 0.) p
Signature: Telephone:370Y-,7-i V ;-Z,- U Expiration Date:
3.3 For ResidenS' I Remo el 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
❑ I 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
Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 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 Constructioi
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 whit
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
❑ Deck ❑ Pool
❑ New Construction*
❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ Accesso_py Bi ,q. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/ arage)
(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
EI Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
esCr,V/.I n U, prs poSa� w0;'r�'
Et fOry;y L. T3MTED'CLa51RLtGTtrul�d GT
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Item Estimated Cost ($) to be completed by permit applicant
1. Building
/-. clecirlcal
3. Plumbing
4. Mechanical (HVAC)
5. Tot2l=(1+2+3+4)
`.. , �yr 4' .:._: (?O;;E:<CGrel��etefi VY`lEL1;"f3tNEi?t'.5��.ger� Or,C0i2'`'3ctOF;;a3']ClileS IDP JLttldJFic7-, t`',BiT:1[t) `ass �-
a
of the subject property hereby authorize BGLYf' 4��S/
to n my be in all matters relative to work authorized by this building permit application.
ignature of Owner Date
/l r i (eoserld s Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to he best of my knowledge and belief.
ine nder th ins and enalties of perjury.
Signature of Owner/Authorized Agent Date
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