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ADDITION
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ARTHUR THOMAS JR,
PRA
7 WOODCOWOODCOCKROAD ®0 N�M��R
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1999
1999 RESIDENTIAL
RESIDENTIAL
S CTTQN-Pt3UlpERT t fliVl�� ttStitl IAt.Ti tit2lSt) AGENT`::: .
2.1 0,A ner of Record:
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Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
..:....: .i::.:.:: ::i :!:...::.:.:.:..:............:: :'i..:.
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3.1 Licensed Construction Supervisor:
Not Applicable 0
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
3.2 Re istered 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 El no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
Address
SNnature 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.4shburion 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 PERFOR:vt 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
bt ildinss 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
engag&s 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 the section sign below:
Signature:
Your signature carries certain response �lities, including but not necessarily limited to, general liability
--- RP InIv 7 1999
NOTICE TO LICENSED CONTRACTORS: 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)
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Workers Compensation Insurance affidavit must be completed and submitted with this application. FVes
e to pirovide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑' no
5.Total =(I+2+3+4)
* Estimated Total
S / 5j 0 00
(please print)
I, , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I j� as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are t and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date
Page 3 Rev Jule 7 19oq
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RESIDENTIAL ❑ FO UNDA TION ONL Y 1999
$25.00 APPLICATION FEE IS,NON-REFUNDABLE
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