BP-2005-42056T T(,T1lTATTT 1 T
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caner of Record:
72.
li�l���v �� � � �
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
75
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
Gignature 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
tCtt% IV, M 4.4) Ca `
wmers Name (print
Signatur
b signing the above, t�home owner acknowledges tha there will be no eligibilty to the Guaranty Fund
� " /9
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 ion ign below:
Signature:
our signature carries certain responsibilities, including but no cessarily limited to, general liability
C:\bldg.forms\Bldgapp.res.wpd
Page 2
Rev. January 2005
RESIDENTIAL
n ction
provides in the Rules and Regulations section that an Construction
NOTICE TO LICENSED CONTRACTORS: The Building Code p gu Y licensed Co
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 ❑ alteration ❑ repairs
❑ chimney/
❑ woodstove
(energy report required) (energy report required)
fireplace
❑ deck ❑ pool ❑ accessory bldg. [V r placement 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- g Y
rr-A�tl✓J
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:
/
�Icl�t&�a'L i - TfJD cS tYr 5 G7 fi
trG� t`K [ (--w�
>` clOaIL5
Item Estimated Cost ($) to be completed by permit applicant
1. Buildin2 0
00.
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4) , * Estimated Total $Q
I , as Owner/Authorized Agent hereby declare that the statements and information
,e the foregoing application are true afd accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signore of 0wner/AuthoizedAgent Date
C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January 2005
RESIDENTIAL
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE is " .e.
4. HOLD subject to Zoning Board of Appeals action:
Date:
Comments:
Inspector's Signature
,. Date:
Applicant informed of above Date:
Comments: —
- Time:
Clerk:
Total Permit Fee: $ 00 Less Application Fee $ 25 00 Remaining Balance $�
TOTAL FEE: (b O .4) 6 Gross Area - New Construction total sq. ft. All-;?.
Gross Area - Alteration total sq. ft. -- s
Permit Issued To -?re Z1_ /;4 C k /9 e (:IA41 AI G � � � �� � ,v � t< o r r ,� k/