BP-41193KLSIDENT1AL
1. Date plan reviewed:
2. DENIED (see project review
worksheet):
3. HOLD
reason:
4. HOLD subject to Zoning Board of Appeals action:_
Comments:
Date:
Date:
Date:
RESIDENTIAL
r
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE is
1.4 Water Supply (11GL c 40 § 54): I
�►/e��/� ..5 Sewage Disposal System:
CAbldg.forms\Bldgapp.res.wpd Page 4
Rev. January 2005
CAbldg.forms\Bldgapp.res.wpd Page I
Rev. January 2005
RESIDENTIAL
RESIDENTIAL
2.1 Owner of Record:
Name (print) 26
^ _ Contact Address Phone Number
Name (print)
Contact Address
Phone Number
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor / License Number-r' ^
Address 72-5 Expiration Date IL`2/D�
Signature l Telephone�1��3
3.2 Re ered Home Improvement ontractor: Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑
no
` If no, go to the next section!
r' Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name A5/7w -8 ��f ea,r-f 1 (—/l
Address 70, � 5��
S3
Registration Number (if none, state "none")
Expiration Date -0116
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
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
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 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 if a 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/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.
If you are applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
C:\bldg.forms\Bldgapp.res.wpd Page 2
Rev. January 2005
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)
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
❑ new construction* ❑ addition
(energy report required) (energy report required)
❑ deck ❑ pool ❑ accessory bldg.
(shed/garage)
* If new construction, please complete the following:
Single Family: no. of bedrooms
❑ alteration ❑ repairs
❑ replacement window/door
no. of windows doors
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):
El HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
Air conditioning - (separate unit)
11 None of the above to be provided
11 Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:,
Item
5. Total = (1 + 2 + 3 + 4)
❑ chimney/
E ❑ woodstove "
fireplace
jjpr
❑ other
❑ demolition
(specify below):
(specify below):
Estimated Cost ($) to be completed by permit applicant
* Estimated Total
(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
�O-w , 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. > er the pains andpenalties of perjury.
Signatur of Owner/ �orizedAgent Date
C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January 2005