BP-62518comments:
Date:FEB 2 3 2H
Inspector's Signature:
Y> Ei,tiop 9,`AI'PLICAIrIT`RIOTtFIC WTIOAi , °
Applicant informed of
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Comments: (
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Less Application Fee: $25.00
Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
TOTAL FEE:
7 6
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
2
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Permit Issued to:
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MINIMUM ❑ Approval in Part (Per 780 CMR.5111.13)
CONSTRUCTION PLANS E SITE PLAN ENERGY REPORT
Page 1
Page 4
2, = I?ROPERTY OWik4ER,
". PIAVTHORIZED AGEMT
r Record:
2.1 w7e-
/l o 4 e I
3,n S S1.,�e S Ce r-n e,r AV rjD�H3� ✓�j�3
Name (print)
Contact Address Phone Number
2.2 uthorJ'zed A nt:
/��,-�
Name (print)
Contact Address Phone Number
9.ra ova, : �`Zi�✓@ , .r ..t �S. .:v, l. ale . .. "... s.SECTION 3-:cbNSTRUGTION.SERVICES
„r...., s'i � _...L
3.1 Licensed Construction Supervisor/Specialty License :
License Number: O / 2 0.2 %
f
Company Name/Contractor Na/me:
Address: b / or7�r �� %� ca / .S —7 7—Expiration
Date:
Signature: elephone:
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? Yes ❑ No
Are you claming exemption from the requirements? ❑ Yes No
If Yes, Go to Section
/3.3
Company Name/Contractor Name: r Cjh e � /, ��
Registration Number (if none, state "none"):
`� 3 6 O
Address: �� �7` r� ucr /6t4 / i� T�� vSe7`/�
Signature: ! T� Telephone: —7
Expiration Date: J e? / Z
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
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print):
a
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 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 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
vcCTiON:4=, WOR6SER'S" CQMFENSATION iNSURAi�ICE AI=F1DAVfT (iyIG1 c"" 1 2 25} :' .
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to�°vide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: [NYes ❑ No
s..,. ,.SECTION 5%. DESCRIPTION OF PR(3P,OSED'WORK°(CheckaI["applicaliE,e)
❑ Deck ❑ Pool a Repairs l! Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) /) (Specify below)
ran [emu/� �ckT`•-rooyn_.
❑ 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 conditioning (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuet-Oil Other
Description of proposed work: S T-/ �x,Is, 7_ AZAS "ell 11 ,I-
/r�s/�. 'Y S Q4 t! mil. X4,rT,c� r i,/ s/c-wev a5.
• "..""'SECTION 6 ESTIMATED•CONSTRUC,%ION,COST... .....< .
Item Estimated Cost ($) to be completed by permit applicant
1. Building Z eloo
2. Electrical
3. Plumbing
4. Mechanical (HVAC) 2
5. Total=0+2+3+4)
SECTION 7A OwPdER AU HORIZATiON�
r , ,,... (to becampieteci when owner!sagent cr contractor appftes for.butidng permtt)�,,.? q.," _..:
lease Pri
I, j'V �Q1J1 C� as Owner of the subject property hereby authorize LU
to act on my behalf, in all matters relative to work authorized by this building permit application.
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($)Signature of Owner n„ µ Date
SECTION 7B = OwNE fAt1THORi±ED AGENT DECLARA rlt}1 i
4-, Ah' as Owner/Authorized Agent 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 the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date
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