BP-41307ICG�JLIJ>u1r1�1�L _ _ _—
y .SECTION 8 — i SPECTOR'S REVIEWCOiv MENTS
1. Date plan reviewed: p�(}
2. DENIED (see project review
worksheet): Date:
3. HOLD
reason: Date:
i
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: L Date: O
SECTION 9 - APUCANT NOTIFICATION
Applicant informed of above
Comments:
Date: Time: Clerk:
SECTION 1€1- OFFICLIINSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: S 25.00
Remaining Balance: S
TOTAL FEE:, j' Gross Area - New Construction total sq. ft. A�
Gross Area - Alteration total sq. ft.
Permit Issued To --
ADDITIONAL COMM ENTS/SI ETCHES
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RESIDENTIAL
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-MANSFERABLE
SECTION'I - SITE INFORMATION
NUMBFR OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1 Property Address:
1.2 Assessors p & of Number: � �j
�? /A/...��,�
M LotL2� -
Nearest Cross Street:
1.3 Historical District ❑ yes ❑ no
Subdivision Name:
Total Land Area Sq. Ft.:
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
/.4 Water Supply (MGL c 40 § 54):
1 'Sewage Disposal System:
Page I Rev. January 2005
f
uF.SMENTIAL
I
RESIDENTIAL
i, ,)
2. I Owner of Record: V,/,
Name (print) �-
Contact Address Phone Number
2.2 Authorized Agent:
-
i
I
Name (print)
Contact Address Phone Number
• E TIO`T 3 - . NL TR ('TI V E N'i;.. E
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor ;
License Number
Address
Expiration Date
Signature
Telephone
3.2 Registered Home Improvement Contractor:
I
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑
no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
Address
Sigrnture Telephone
Expiration Date
3.3 For Residential Remodel Work Only
(i
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, AL4 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 1
3.4 Homeowner Exemption - One & Two Family Only
I
/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 im olving the structural elements ofbuildings
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 ifa 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.ishe resides or intends to reside, on which
there is, or is intended to be, a one or two familv 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.
Ifyou are applying under this sect on sign below:
Signature:
Your signature carries certain responsibilities, inclu tng ut not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed 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 (MGI,`c.152:§ 25)
Workers 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 ❑
n
0
- : SECTION 5 - DESCRIPTION OF PROPOSED NVORK_(check all applicable)•
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(enero report required) (energy •eport required) fireplace
❑ deck ❑ pool acres§ory bldg. ❑ replacement window/door ❑ other ❑ demolition
(Shed larage) no. of windows doors (specify below): (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) - fitel 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:
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
1. Buildin
2. Electrical
3. Plum inLy
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $ T &v r e)
SECTION 7A - QWNER AUTIiORIZATI0N
(to be completed when owner's agent or contractor applies for "building permit)
(please print)
I, , 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
I,��� rl �J , as Owner/Authorized Agent hereby declare that the statements and information
the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
al
Signature of Owner/Authorized Agent Date
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