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SECTION 2 ;`PROPERTY OWNERSHIP/AUTHORIZED AGENT
2V Owner Record: -
�i�vL c: C Pe—S
��� tv�JlTe �� �2vN ��•G�- ��$s
Name (print)
Contact Address Phone Number
Authorize Agent:
&Fill
- :
Nam Tint)
Contact Address Phone Number
SECTION 3.- CONSTRUCTION SERVICES
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 claming exemption from the requirements? ❑ 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:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598 ,.."l
❑ 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
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-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
NOTICE TO LICENSED CONTRACTORS: The Building Code
Supervisor, whether or not they have taken the permit are resp
SECTION 4-WORKER'S COMPEN'
Worker's Compensation Insurance Affidavit must be complet(
affidavit will result in the denial of the issuance of the building
rovides in the Rules and Regulations section that any licensed Construction
isible for code compliance. (see Appendix of 780 CMR F�5.2.15)
TION INSURANCE AFFIDAVIT (MGL c 152 § 25)
and submitted with this application. Failure to provide this
ermit. Signed Affidavit Attached: ❑ Yes ❑ No
SECTION 5 -DESCRIPTION OF PROPOSED WORK (Check all applicable) .
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstown/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify bellow)
❑ Addition ❑ Replacement windo door ❑ Demolitiom
(Energy report required) No. of windows _ Doors _ (Specify bellow)
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of B the
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, of ler (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electrici y, other
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric F jel Oil
--t ,'Description of proposed work: A �
l
Other
5. Total= (1 +2+3+4) I I
SECTION 7A "OWNER AUTHORIZATION
(Please Print) O �J
I, A ►3-*ee- L-C! PeS as Owner of the subject property hereby authoriz
to ac n my be 21f, in aers relative to work authorized ty this building permit application.
I C `"
+Si(latu!reof 0 ner d Date
i, G/ f j}°L 1 f�C� as Owne /Authorized Agent hereby declare that the statements an(d information
on the foregoing application are true and accurate, to the besl of my knowledge and belief.
Signed under the painydnd penalties of perjury.
Date
1. Date plan reviewed:
2. DENIED (see project review worksheet):
3. HOLD
Reason:
4. HOLD subject to Zoning Board of Appeals action:
Comments:
Date:
Date:
Date:
Less Application Fee: $MO0 ,�O. o Remaining Balance: $—
Total Permit Fee: $ 0
Other $ Amount $
TOTAL FEE: Q, 0 C% Gross Area - New Construction total sq. ft.
p Gross Area - Alteration total sq. ft.
Permit Issued to: / O 0 L ®fe�C 5 6,c i "-A C C #',,S 7-;--
0 3 S�s�So�/
o bV SCIt'e/V /'ew
❑ SPECIAL F ERMIT (Per 780 CMR 111.13)
$2 5.00 APPLICATION FEE I5 ON RE-FUNDA :3LE & NON-TRANSFERABUE
SECTION
1 -SITE INFORMATION
1.1 Property Address
s't
Nearest
1.2 Assessors Map Lot Number:
3
Cross Street:
Map Lot -
Subdivision Name:
1.3 Historical District ❑ Yes ❑ No
Total Land Area Sq. Feet:
Has application been submitted to the tHistoric Commission?
❑ Yes ❑ No Date:
1.4 Water Supply (MGL c40 4):
1.5 Sewage Disposal Syste
❑ Municipal Ei" rivate Well
❑ Municipal d n Site Dispfosal System
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT