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BP-17953RESIDENTIAL Date: Date: Date: Date: 2000 RESIDENTIAL 2000 7777=- ❑FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON•TRANSFERABLE C:'bldg.forms' 13ldgapp.res.%%pd Pare 4 Rev. Januan 13. 2000 C:\blde.fonns\Bldeapp.res.wpd Page 1 Rev, January 13.2000 RESIDENTIAL III' . slr[r7� 2 - rrzaPt ftmt e�ry i tztlirl,�t rt�lztzEu :�cEr 2.1 Owner of Record: BARRY R . HODGE 440:4ILLIAM STREET {% BARRY/ JANICE HODGE NEW BEDFORD, MA 999-2930 Name (print) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number _...._ _ ...:::.:..:::..: . .:: ;:::::::::.;:: SECTI©ti»>COSTRl.CT1ONSERviCES ...::: . 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 claiming exemption from the requirement? ❑ yes ❑ no If yes, submit the required affidavit! Company Name Registration Number (if none, state "none") Address Sigr tore Telephone Expiration Date 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 Owners Name (print) Signature by signing the above, the home owner acknowledges that there will be no eligibilty 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. Exception: An Homeowner performing Work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner P Y Pe g g 9 P P 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 dwelline. 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 secti sign elow: Sienature: ur i_ atur rries certain responsibilities, including but not necessarily limited to, general liability RESIDENTIAL 2000 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) SF�G"X'10N 4 » W©RK R'S ..0 P1fNSATI(%`., i€NSURANCE r�1 FCUA Vi1T 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 ❑ no SECT[t11� 5 ,DESCR PTIfli�I: (11 PRU1'©5ED �VQR[ .P.0 S 11 apPhcA>al�j ❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ Xwoodstove (energy report required) (energy report required) fireplace ❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition (shed/garage) 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) - fuel 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: INSTALLATION OF CRANE MODEL 404 SOLID FUEL STOVE, UTILIZING EXISTING FIREPLACE HEARTH/ FLUE S> CTIfIN 6 ESTI L1AT EDO\$TRUC iI�N Cfl5T5 Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbiniz 4. Mechanical HVAC 5. Total = (I + 2 + 3 + 4) *Estimated Total $ 700.00 7 QIVNER AUTIf R1Zzi I1t?N :: ::::.;'.;:.;:.;:.;:.:.::.:::.;:.;.:.;':.;:.::.;:.;'.::.:..:.::.::.:::.::'.;:...........: '.:::.:::. . ECTIO :.;:::.;::....:::.;::.:'.::.:::.......:.:.:'.::.:.:;::'.; ::::......:...:.:.::..:.:::..:::::........ ..:..::::..:..:...... Q ......;...:... ..:::::..:::...: .: + ... ..:::::..:: " '.' (ta be co-tnpletd �vhen;nwnr r s A ent+jr contractor a tes vt: al. tt yr tilt :.:::::: r<';;>;:;::>`.>'::: `:::....... (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 ": SECTC{7�i iB20' ,SEi21AU1t1U121ZE17ACNT:ffl C i2ATtt �1 •'> » : I, BARRY R . HODGE , as Owner/AXUMX0CkAg01X 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 th4pains d pe alties of perjury. 7 NOVEMBER 2000Signature f Ooriz Agent Date C:'bidc.forms\Bldeapp.res.NNp�d Paee 2 Rev. January 13. 2000 C\blde.forms\Bldeapp.res.wpd Paee 3 Rev. January 13, 2000