BP-34556RESIDENTIAL 2004
❑ FOUNDATION ONLY
$25 00 APPLICATION FEE IS NON-REFUNDABLE do NON -TRANSFERABLE
1. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals (see project review worksheet): Date:
5. DENIED (see project review worksheet): Date:
6. HOLD reason: Date:
7. HOLD subject to Zoning Board df Appeals action: Date:
8. Comments:
RESIDENTIAL 2004
❑ FOUNDATION ONLY
$25-00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
- -- �- municipal by Un Site Disposal Syrstem
Rev. January 1, 2003 CAb1dg.forms\B1dgapp.res.wpd Page 1
Rev. Januartv 1- gnm
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R F.CIIIFNTI A I .
2004
RESIDENTIAL
2004
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8 4 i
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2.1 Owner of Record:
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V 1 t��Csor►�T t�kd tTJ �Jt'° ;
Name (print) Contact Address hone Number
2.2 Authorized Agent:
`1'kcc���� Sob b33 • ��ro
Woo � e MM 1�Mr S
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Contact Addr Phone Number
4 rn.o(Z� 13e�
Name (print)
go Yt7i�l )CCiiliL7CIUl!7SERC7IE5 w _ .mr
3.1 Licensed Construction Supervisor: Not Applicable ❑
•
Licensed Constru tion Supervisor 1 1 m—�i
License Number C 5 0 7 V
Address -?. 0 go
Expiration Date
, oR e
O 9/ 3/o y
�1ephone(5,,r)Z.4.7.Tyer
Signature
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 ❑ AO
If yes, submit the
required affidavit!
Company Name ,e , _ S
Registration Number (if none, state ❑ none❑)
3 yG
Address ? of 16 3
Signature ephone �'Of g33 •
Expiration Date I A / CIO tr
= 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:
Horne 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)3BRS 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:
y Your signature carries certain responsibilities, including but not necessarily limited to, general liability
INOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constrtuction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.1�) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to proviide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: 5Kyes ❑ no
)(new construction* ❑ addition ❑ alteration ❑ repairs Archimney/ 10 woodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other [ED 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 3
Two Family: no. of bedrooms unit 1 no. of baths unit 1
no. of bedrooms unit 2 no. of baths unit 2
V Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify): 0 t e WA evI Ait
❑ 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
X Hot Water: Gas A Electric Fuel Oil Other /I
Brief Description of Proposed.Work: n S ('v.A I tv-� I K 3 d do 3 Q
ovhE a- W un r ekt" Otte 4r� Q T 10 C" C u ndc2 .
t
Item
1 Rnilrlina
F.lertriral
3 Plnmhino
4 Merhnniral (HVAC)
5.Total =(1+2+3+4)
Estimated Cost ($) to be completed by permit applicant
4a. V.2S
(0 0 d 0
7000
7500
* Estimated Total $ 1 93 Yd tr
(please print) (
as Owner of thediect property hereby authorize R •e• tt�rm ss
to act on my behalf, in all matters relative to ork u i is building permit application.
Gcc <�t 3%1
Signature of Owner Date
%kk1AM --v►
on the i
Signed
Signature of Owner/Authorized Agent
as Owner/Authorized Agent hereby declare that the statements alnd information
to the best of my knowledge and belief.
Date
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