BP-49763SECTION 8 - INSPECTOR'S` REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: Date: � % ? d
S CTIO '9 -APPLICANT NOTIFICATION
Applicant informed of above: Dat . /—J Time: �l�i` Cler .
Comments: M"
OFFICE/INSPECTOR'S NOT
- - SECTION 10 - �
Less Application Fee: $Ra-a - Remaining Ba a ce:
Total Permit Fee: $
Other $ Amount $ �J
TOTAL FEE: Gross Area - New Construction total sq. ft.
.Gross Area -Alteration total sq. ft.
Permit Issued to:
SECTION,11-ADDITIONALCOMMENTS'ISKETCHES. ' '
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
1.4 ter Supply (MGL c40 s54): 1.5 ewage Disposal System:
M unicipall I/Private Well ❑ Municipal Rt"'On Site Disposal System
❑ CONSTRUCTION PLANS 0 SITE PLAN 1:1 ENERGY REPORT
R SIDENTIAL - NOTICE TO LICENSED CONTRACTORS: The Building Code rovides in the Rules and R 1 f cf th 1'
" ` SECTION 2 -PROPERTY OWNERS
IP/AUTHORIZED AGENT
.1 Owner Record:���
r HrLha o rien
_
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 -'CONSTRUCTION SERVICES'.' .
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 claming exemption from the requirements? ❑ Yes p 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-
6--JESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place -oom 1301, Boston, MA 02108, 617-727-8598
R
❑ 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
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. y
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. A
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. li
If you areAapllying dd
uer this section sign below:Signature
Your signature c rrie ertain responsibilities, including but not necessarily limited to, general liability
p egu a Ions se on at any icensed Construction
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 §'25)
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: ❑ Yes ❑ No
SECTION 5 -'DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration Chimney/Fire ace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. oofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
i❑ 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 c _
onditioning - (separate unit) '
❑ None of the above to be provided
❑ Hqt Water:• Ga Electric Fuel Oil Other
Des ption of proposed work:
SECTION 6 - ESTIMATED CONSTRUCTION COST—'`
Item Estimated Cost ($) to be completed by permit applicant
1. Building41.2
; ;
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =0+2+3+4}
SECTION7A - OWNER AUTHORIZATION'`a
(to be completed when owner's agent or contractor applies for building permit)
(Please -Print)
1, , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date ,
SECTION 76-°OWNER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent hereby declare that the statements and information
ILIon the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
w
7 0`7
Signature of Owner/Alit h nzed Agent Date