BP-18355RESIDENTIAL
❑ FOUNIDATION ONLY
$25.00 APPLICATION FEE IS NO1N-REFITNDABLE & NON-TRANSFERAIKLE
2000
C:!:bId2.forms\Bld«app.res. Nvpd Pate 4 Rev. January 13, 2000
C:\bldg.forms\Bldgapp.res.wpd
Rev. Jianuary 13, 2000
RESIDENTIAL
2000
RESIDENTIAL
tcrroN=pool?El �r c�rvN iiSittl=ItI1tORM .O A �TGENT
2 1 Owner of Record:
ZJ
Name (print) v
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
...
::. _ ....
SECTI41 .CQSTRI,CTIE3N:SER�3t E5. ,.
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
tre Telephone
Expiration Date
3.3 .:.or 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
Owners Name (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty 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 familv 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: Y
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides ill the Rules and Regulations section that any licensed Construc+lion
Supervisor, whether or not they have taken the permit are responsiblelfor code compliance. (see Appendix of 780 CMR R5.2.15)
S CT.1 4»tvdttrk l2'SCU�IP1vNSAIC 1II�fS>)R NCIA I~FCU VtC m(; e152 2
Workers Compensation Insurance affidavit must be completed nd submitted with this application. Failur to provide tftiis affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Xyes ❑ no
❑ new construction* ❑ addition
alteration ❑ repairs
❑ chimney/ /1�1 wcoodstove
(energy report required) (energy report required)
fireplace
❑ deck ❑ pool ❑ accessory bldg. 11
replacement window/door
❑ other ❑ de=olition
(shed/garage)
Po. of windows doors
(specify below): (specify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit 1 no. of ba
s unit 1
no. of bedrooms unit 2 no. of bat
s unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity,
other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, elec
ricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane,
electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fue
Oil Other
Brief Description of Proposed Work:
60 r
Item
Cost ($) to be completed by permit applicant
I, ��_ (C , as Owner/Authorized Agent hereby declare that the statements and infformation
on the foreg ng application are true and accurate, to the best o my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature o'fOwner/Authorized Agent
01,
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Rev.:January 13, 2000