BP-44652RESIDENTIAL
FOUVDA
$25.00 APPLICATION FEE IS NON-R]
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I'
,LE arc NON -TRANSFERABLE
Rev. January,�005
Exception: Any Homeowner pertotmmg worx for wmcn a rSuuunjg rU111— - 1-1-- —"""^ —F. -- v ....W ..---- -- - , r- - ----
engages a pe7son(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 9a 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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Rev. January 2005
I C610 S , as Owner/Authorized Agent hereby declare that the statements and i �iformation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Si n der the pains and penalties of penury----
a re of Owne Authorized Age t 'Date
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