BP-47788RESIDENTIAL NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any liceinsed Construction
SECTION 2-`PEJPERTY OWNERSHIP/AUTHORIZED
AGENT ,
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2.1 Owner Record:
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Name (print)
...,.
Contact Addres Phone Numb-
5
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 -CONSTRUCTION SERVICES
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 claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company 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:
ome Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
1 am a Homeowner performing all the work myself.
Owners Y-N
V
Name (print):
Signature:
By signing the above, the omeowner now edges that there will be no eligibility to the Guaranty Fund
Date: - /0 "%
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(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:
A
Signature:
Your signature carries cerW4%Zosponsibilities, including but not necessarily limited to, general liability
bupervisor, wnetner or not tney nave taKen the permit are responslnie Tor cooe compliance. (see Hppenolx oT /uU l NIK r 5.2.15)
SECTION 4' WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25) . -
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide thiis
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ Nto
SECTION 5 -DESCRIPTION OF PROPOSED WORK (Check all applicable) .
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove.+/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify bellow)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows _ Doors (Specify bellow)
*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 /Fuel Oil Other
Description of proposed work: /
(Please Print)
as Owner of the subject property hereby authorize
to act on I; behalf, in all matters relative to work authorized by this building permit application.
Signature(of Owner Date
SECTION 713 -OWN ERIAUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent hereby declare that the statements and iinformation
on the foregoing afiplicalion are true an�accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
JQ
Signa re of Owner/Authorized Agent Date