BP-38628RESIDENTIAL
1. Date plan reviewed:
2. DENIED (see project review
worksheet):
3. HOLD
reason:
4. HOLD subject to Zoning Board of Appeals action:
Comments:
azz�j'--� �
CAbldg.forms\Bldgapp.res.wpd
Date:
Date:
Date: �1d/
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1
RESIDENTIAL
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE NON -TRANSFERABLE
CAbldg.forms\Bldgapp.res.wpd Page 1 Rev. January 20q)5
RESIDENTIAL
RESIDENTIAL
A.1 Owner of Record:
n ^
Name (print) Contact Address
2.2 Authorized Agent:
Name (print)
Contact Address
FOTI'
E ToLICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction R5
rvisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR .2.15)
Phone Number 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 ❑
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0
Phone Number
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor License Number
Address
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
Expiration Date
Not Applicable ❑
Registration Number (if none, state "none")
Expiration Date
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
l Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name
Ir
,7 L�1, V r—T
by signing the above, the ho( (wner 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 indirectly 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.
or the purposes of this section only, a "Homeowner" is defined as follows: Persons) who owns a parcel of land on which he/she resides or intends to reside, on which
th a 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
o e homd in a two-year period shall not be considered a Homeowner.
/ L
If you ar applying under this's�c on sign below�j
signature cartes certain f esponsib' ties, including but not necessarily limited to, general liability
❑ new construction* ❑ addition
(energy report required) (ene orix wired)
❑ deck ❑ pool sso bld
(shed/garage) '
* If new construction, please complete the following:
Single Family: no. of bedrooms
❑ alteration ❑ repairs ❑ chimney/
fireplace
❑ replacement window/door ❑ other
no. of windows_ doors_ (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: I z n
Item
❑ woodsltove
❑ demol'ition
(specify be low):
Estimated Cost ($) to be completed by permit applicant
15. Total = (1 + 2 + 3 + 4) I -Estimated Total $ ^ /t `2
(please print)
1, , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
Date
I 2 a l rr�,� i , 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
the pains and penalties of perjury.
of
Date
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