BP-38745RESIDENTIAL
ur�SIDENTIAL
x' 17E>1�vTcdiv�METs z ❑ FOUNDATION ONLY
1. Date plan reviewed:
2. DENIED (see project review
worksheet):
3. HOLD
reason:
4. HOLD subject to Zoning Board of Appeals action:
Continents:
Inspector's Signature:---(
Applicant informed of above Date: 5
Comments: /1/yIn JJ AP
Date:
Date:
Date:
Time:--; Clerk:
Total Permit Fee: $ �}
Less Application Fee: $ 25.00 Remaining Balance $
TOTAL FEE: `° -1 ?J ` Gross Area - New Construction total sq. ft.4) A��
` ( Gross Area -'Allteration total sq.
Permit Issued To / / Q&t ei .o :GL� ,L/7Z. % %i
11,5- al
'
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RESIDENTIAL
2.1 Owner of Record.
M R. P1's, -rN 0 M A S Q atiro, T
G S ki ' 7 H AP-T 0 sT, 508" �� `F- 6 6 4 G
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
ANTHOPX * WN ITC Co 11J5? ANC, XPL6WOOP AVr- 92-3662
Name (print) Contact Address Phone Number
y
�. .5 ✓ a. Urf41-
3.1 Licensed Construction Supervisor. POOiECT A NTI-10�,J Not Applicable ❑
Licensed Construction Supervisor License Number O 5'7 Sy0
Address g =DLEWOOP A VF N0. DA2 T Expiration Date
Signature Telephone50� Y 9Z-36G Z, 2 9 % ZOo b
3.2 Registered Home Improvement Contractor: A&J I NO Ny t- wtt 1TF CO R57, Not Applicable ❑
/NC.
Are you a Home Improvement Contractor subject to (780 CMR-6)? El'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 ANT` o N 4- W 'rl l 'i'(r c o N S,7,
1U( . Registration Number (if none, state "none")
Address $' TP C "2 `0- > A Vf - /VO , DA/C 7, 112397
Signabare 0,Telephone 5'08' cI 1 2 - 3 (( Z— Expiration Date 2/.?4 2oc6
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
Owner's Name (print
Sig nature
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
3.4 Homeowner Exemption - One & Two FamilyOnly
Y
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 supervisingpersons 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 ofthis 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
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RESIDENTIAL
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: ❑ ye-s ❑
-Wf o
L9'new construction*
(energy report required)
❑ deck . ❑ pool
❑ addition
(energy report required)
eaccessoy bldg.
* If new construction, please complete the following:
Single Family: no. of bedrooms
❑ alteration ❑ repairs
❑ replacement window/door
no. of windows doors
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
11 Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):_
11 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)
El None of the above to be provided
Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: .20' x.2
.9Qavc' f1.y�EZ7 ONTO 'X/STING— Gi9/rr4CrC /9 N
Cif ".-REW r4y ZIAIPA72 ce1.s7',-- UC 71c1V
❑ chimney/
fireplace
❑ other
(specify below):
❑ woodstovte
❑ demoliticm
(specify belo-,w):
4V 17H STo -,C-1 Cr t
iye"4 r
Item Estimated Cost ($) to be completed by permit applicant
1. Buildine 7 coo,
2. Electrical ,0 p ca
PlumbinLy ti t
3 0 00. _'
4. Mechanical AC
5 Total (1 + 2 + 3 + 4) * Estimated Total $ 2 2z 0 O O. no
� �: ,�z . � ��"� ( . b c mplet�d when owner s agen�or contracto a hes 1'or burldtng I►exmtt) � � ��� '� ,`�
(please rint)
as Owner of the subject property hereby authorize r
to act on my behalf ' alk matters relative to work authorized by this building permit application.
Sig ture of Owner Date
k.J 6s 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 under the pains and penalties of perjury.
of Owner/Authorized Agent
-7/6S-
Date
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