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BP-2001-21217J 2001 SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT , �t 2.1 Owner of Record: j % Z � �% ` ©j q( 0 C AUheei l 7" 107 &SSicLLS1-71L6S— Name (print) Contact Address Phone Number 2.2 Authorized Agent: �K ��J k -�y �) Name (print) Contact Address Phone Number SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: ` 11 Not Applicable ❑ Licensed Construction Supervisor License Number �� 7 Address Al'ut'Am /a ocg4(,-7 Expiration Date Signature Telephone 3.2 Registered Ho Improvement Contractor: Not Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR-6)? Vyles ❑ no If no, go to the next section! Are you claiming exemption from the requirement? ❑yes no If yes, Fubmit the required affidavit! Company Name /lt Registration Number (if none, state "none") Address 44,4bL P K� /0 1� Signature Telephone o �-,F3 - , ? Expiration Date p 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 Date 4 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 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: 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(.) 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 19, 2001 __ _ _ RESIDENTIAL _ 2001 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 are responsible for permit code compliance. (see Appendix of 780 CMR R5.2.15) SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL 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 ❑ no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) ❑ new construction* ❑ addition alteration ❑ repairs ❑ chimney/ ❑ woodstove (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: S 1 ) SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost ($) to be completed by permit applicant 1. Buildinty 2. Electrical 3. Plumbin 4. Mechanical HVAC 5. Total = (1 + 2 + 3 + 4) *Estimated Total SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (please print) I, CC /Y1 Z4sh - as Owner of the subject property hereby authorize - to act on my �ch�alff,, inal) matt rs�re/ylative to work authorized by this building permit applicatioon./j /j of ! Mot Signature of Owner Date SECTION 7B . OWNS AUTHORIZED AGENT DECLARATION I> Ct , 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 u4thheins and penalties of perjury. Signature u orized Agent D C:\bldg.fonns\Bldgapp.res.wpd ate Rev. January 19, 2001 Page 3 RESIDENTIAL 2001 RESIDENTIAL 2001 SECTION 8 - INSPECTOR'S REVIEW/COMMENTS 1. Date plan reviewed:�'„� 2. 30 days to review period expires: 3. OK to issue date: 4. OK to issue subject to requested submittals(seeproject review worksheet): 5. DENIED (see project review worksheet): 6. HOLD reason: Date: Date: Date: 7. HOLD subject to Zoning Board of Appeals action: 8. Comments: Date: 9. Inspector's Signature: C 25A ECTION 9 - APPL C TT NOTIFICATION Dater Applicant inform/ f abov j Date* Time; Clerk: Comments: (/ SECTION 10- OFFICEVNSPECTOR'S NOTES Total Permit Fee: $' 00 Less Application Fee: $ 25.00 Remaining Balance $ TOTAL FEE: `2 Gross. Area -New Construction total sq.`ft. Gross Area -Alteration total sq. ft. Permit Issued To- Z Z4 SECTION 11- ADDITIONAL COMMENTS/SKETCHES Alt ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE do NON -TRANSFERABLE ouTir:� _•,�,J,., _ bARTMOUTH BUILDING DEPARTMENT DATE RECEIVED C:\bldg.fors\Bldgapp.res.wpd Page 4 Rev. January 19, 2001 m C:\bidg.forms\Bldgapp.res.wpd Page I Rev..January 19, 2001 V\ � 1777