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RMoRM PLATI
A Copy Of This Endorsed
Plan Most Be Kept On Site
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RESIDENTIAL
0.. SECTION 2, PROPERTY.OWNERSHIPIAUTH.ORIZED'AGENT...:,'
77
-
Owner Record:
� r,SitAL, (4- hP6 )K2
7/�O
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3,t`CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor/Specialty License : License Number:
Company Name/Contractor Name:
Address:
Expiration Date:
Signature: Telephone:
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:
Registration Number (if none, state "none"):
Address:
Signature: 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
�am a Homeowner_performing all the work myself.
r� e
Owners Nammrsignini-the
Signature:
y above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
ate: 1`57 v '
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 Licensing of construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
sh3ll 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
Supervisors. Constructioi
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 the
one home in a two-year period shall not be considered a Homeowner
If you are applying un is S n si n bel
Signature:
Your nature carries ertain responsibilities, including but not necessarily limited to, general liability
r ayc c
Page 3
k SECT;,iUN 8 ,tNSPECT'OR'S�RE1f[E
1. Date plan reviewed: MAY 2 1 2010
2. DENIED (see project review worksheet):-
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments: -
Less Application Fee: $25.00 Remaining Balance: $ -S
Total Permit Fee: $ 3
Other $ Amount $
TOTAL FEE:ti Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: L�?3�S"i7'iu�r�"Ii— ;V VX ;2/_ /— �1?s.6T,4,7a—
Page 4
RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13)
i
1.1 Property Address: %5zlorvi l%/G.�/ _ 1.2 Assessors Map &Lot Number.
Lot Area (sf.) IX44e Frontage f (y /, Map Lot 01
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard Year Built
Rear Yard
❑ Altering more than 25% per side of building
,4�Water Supply (MGL c40 s54): 1Vicipk[1,1�nfi
wage�sposal S stem: Has application been submitted to the Historic Commission?
6'�nicipal ❑Private Well Site isposal System ❑ Yes ❑ No Date:
❑ CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT
Page 1