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BP-43734Date: Date: RESIDENTIAL ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 2005 C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev. Janmary 2005 E 11AL RESIDENTIAL M 2.1 Owner of Record: Ro� Name (print) 2.2 Authorized Agent: Contact Address Phone Number Name (print) I Contact Address Phone Number 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor: 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 Address Signature Telephone 3.3 For Residential Remodel Work Only Not Applicable ❑ Registration Number (if none, state "none") Expiration Date IPERSONS 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 Nam \/���(T\.1,\rint) -Z" � A- CAI^ by signing the above, the home 6vner acknowledges that there will be nTerigibilty 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 bplow: /,-? /% Your signature carries certain responsibilities, including but not necessarily limited to, general liability 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: iVyes �] m Q) ❑ 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 ❑ chimney/ ❑ woodstove fireplace ❑ replacement window/door ❑ other ❑ demolition no. of windows doors_ (specify below): (specify below):, 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: u A j, �L © � P I1 W ,4�1 AJA,,V AIA,--/ z Item Estimated Cost ($) to be completed by permit applicant 1 Building 2. Electrical 3. Plumbing - 4. Mechanical AC 5. Total = (1 + 2 + 3 + 4) * Estimated Total , as Owner of the subject property hereby authorize in all matters relative to work authorized by this building permit application. Date as Owner/Authorized Agent hereby declare that the statements and information On are true aid accurate, to the best of my knowledge and belief. gned u e pains and penalties- of perjury. V � Signature of caner/Authorized Agent C:\bldg.forms\Bldgapp.rmNvpd Page 2 Rev. January 2005 C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January2r005 bil 77 711'e,?:"Cray Oct' FILE, CQRI'