BP-41937TcE- DENTIAL
1. Date plan reviewed: //Z3 a.
2.30 days to review period expires:
3. OK to issue date: // A
4. OK to issue subject to requested submittals(see project review worksheet):
5. DENIED (see project review
worksheet):
6. HOLD
reason:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
19. Inspector's Signature:
IApplicant informed of above
Comments:
Permit Issued To:
Date:
ZONAL COMMENTS/SKETC7
Date:
Date:
Date:
Clerk:
Date: //,
2005
C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. June 26, 2003
RESIDENTIAL
❑ FOUNDA
$25.00 APPLICATION FEE IS NON-RF
2005
ONI,Y P-.,
`ABLE & NON -TRANSFERABLE
;. iDATE RECEIVED
ENT1
A ONE OR TWO FAMILY DWELLING
Date:
Date:
Date: 917-
Date:
Date:
Subdivision Name: 1.3 Historical District ❑ yes ❑ no
Total Land Area Sq. Ft.: Has application been submitted to the Historic Commissiion?
C) 6i ❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ Municipal rivate Well ❑ Municipal /On Site Disposal'Systrem
C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev. June 216, 2003
i
AFcmF.1vTTAT.
2005
T
2. Owner of Record:
( //
T 0b & -b2 �
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION_CONSTRUCTION`
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
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
Registration Number (if none, state "none")
Address
Signature Telephone
Expiration Date
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:
Houle Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
v
Date
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 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-vear period shall not be c nsidered Homeowner.
If you are applying n r thi se ion sign b w:
Signature:
Yours ture ca s ce m responsibi ides, me u in611t imited to, general liability
u
RESIDENTIAL
NOTICE To LICENSED CONTRACTORS: The Building Code provides in th 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)
SECTION 4 - WORKER'S CODIPENSATION NSURANCE AFFIDAVIT` (MGL c 152 § 25)Aw
w
2005
Workers Compensation Insurance affidavit must be completed anc submitted with this application. Failure to provide this
affidavit will result in the denial of the issuance of the building pe it. Signed Affidavit Attached:❑ yes Cl no
SECTION 5 -DESCRIPTION OF PROP SED WORK (check all •applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woo&stove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demollition
(shed/garage) no. Df windows doors (specify below): (specify lbelow):
* 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 nit 1
no. of bedrooms unit 2 no. of baths unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electri ity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
Cl HVAC (combined unit) - primary fuel, natural gas, propane, elc ctricity, other (specify):_
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oi Other
Brief Description of Proposed Work: Z.
Item
I5.Total=(1+2+3+4)
(plea
t7 act on my Denau,
Signature of Owner
* Estimated Total
, as Owner of the
in all matters relative to work authorized by 1
on the foregoing application are
0
Authorized
Cost ($) to be completed by permit applicant
Ject property hereby authorize
building permit application.
I Date
, as Owner/Auth rized Agent hereby declare that the statements and information
and accurate, to the best of 4 knowledge and belief.
of vedurv..
o A1n:
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Rev. Rune 26, 2003