BP-15814RESIDENTIAL 2000
❑ FOUNDA ION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
C:lbldg.forms`J3ldgapp..res.%cpd Page 4 Rev. January 13, 2000 C:lblde.forms\Bldeapp.res.�vpd Page 1 Rev. Janurary 13, 2000
RESIDENTIAL 2000
NO
TICE: To LicENst:n COYr1UCToxs: The Building Code provides in the 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)
scTl€o�udRlz's col?1v�sarltivrs1RR �tCEllu r €lttc c �5 § 2j
Xa-
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: des ❑ no
❑ new construction* ❑ addition ITalteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. 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 I no. of baths unit I
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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas % Electric Fuel Oil Other
Brief Description of Proposed Work:
i r /
Signed under
Signature
and penalties of perjury.
41
RESIDENTIAL
17nnn
SECTION, >1kR(71'E1tT
' fl4V v`1 RStitPlA[fTlitittlI U ACL V7: ,_ ::::.;::.. ;;:
2.1 Owner of, Record:
On
Name (pri t)
Contact Address P one Number
y
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
Steri
oN'STRITc
3.1 Licensed Construction Supervisor: .�
f-/—,,
Not Applicable ❑
Licensed Construction Supervisor
License Number
Addressb ,
Expiration Date
Signature Telephone
4 4e!�Q
3.2 Regi3ter d Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 C
R-6)? i&5�es ❑ no
If no
go to the next section!
Are you claiming exemption from the requirement? ❑
yes ❑ no
If
es, submit the
required
affidavit!
Company Name
Registration Number (if none, state "none")
'? C�
Address o .�
Signature Telephon
�/ q
Expiration Date G,
3.3 For Idential Remo 1 Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONT
CTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One A
Yhburton Place - Room 1301, Boston, MA 02108, (617) 727-8;j98
Owners Name (print)
Signature
by signing the above, the home owner ackno
fledges that there will be no eligibilty to the Guaranty Fund
Date
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PE
FORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 Licensing of Construction Supervisors: Except for those structu
es governed by Construction Control in Section 116.0, effective July 1„ 11982, no individual
shall be engaged in directly supervising persons engaged in construction, r
construction, alteration, repair, removal or demolition involving the strructural elements of
buildings or structures, unless he or she is licensed in accordance with the rt
les and regulations promulgated by the BBRS entitled Rules and Reguliations for Licensing
Construction Supervisors.
Exception: Any Homeowner performing work for which a Building Permi
is required shall be exempt from the provisions of this section; provides tihat if a Homeowner
engages a person(s) for hire to do such work, that such Homeowner shall ac
as supervisor.
For the purposes of this section only, a "Homeowner" is defined as follow;:
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 detac
ied structures accessory to such use and/or farm structures. A person wJho 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, in
luding but not necessarily limited to, general liability
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