BP-3824952
SECTION 2 - PROPEATY OWNERSHIP/AUTHORIZED
AGENT .-.
2.1 Owner Record:
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Name (print)
Contact Address Phone Number
2.2 uthorized A t:�
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Name (print)
Contact Address Phone Number
-SECTION 3 - CONSTRUCTION
-SERVICES
3.1 Licensed Construction Supervisor /Specialty LicenV
Not Applicable ❑
Licensed Construction Supervisor /S ecial License
p P ty �(✓
License Number:
Address: / A(%
Expiration Date:
Signature: Telephone: ?4`7— ((l /
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V3.2
Registered Home Imp ement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
JIf
Yes, submit the required affidavit!
Company Name: C
Registration Number (if none, state "none'):
Address: Z31 r'tnJ,re�
XV56
Signature: Telephone: �L �I ��CG1i'
1
Expiration Date:
/11
3.3 For Residential Remodel Work Only Q6J11
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Horne Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print):
Signature::
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date:
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 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:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to prpvide tihis
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: es ❑ No
-SECTION 5= DESCRIPTION OF PROPOSED WORK' Check`all a livable
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstovre/Pellet Stove
❑ New Construction" ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify beilow)
❑ Addition 18"Replacement win ow/door ❑ Demolitiom
(Energy report required) No. of windows 4 Doors (Specify beilow)
*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
Description of proposed work:
Other
1), 1 s;
I Item I Estimated Cost M to be completed by permit aoplicafnt I
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC;
5. Total=N+2+3+
(Please Print)
I,
to act on my behalf, in all
Signature of Owner
I, —'
on the foregoing
SkRied under the
, as Owner of the subject property hereby authorize
relative to work authorized by this building,.pernmit applicatl9.rt
n_ n d / A I .1/V
Date
as Owner/Authorized Agent hereby declare that the statements and information
are true and accurate, to the best of my knowledge and belief.
prsnalties of perjury.
rized Agent
Date
Inspector's Signature:
Applicant informed of
Comments:
NUv 1 13 OUS I
Date:
Date: �1� t I Time: 1 Clerk:
�.� Less Application Fee: $25.00
Total Permit Fee: $ S
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
I
Remaining Balance: $
RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13)
CONSTRUCT10il