BP-54903SECTION 2 - PRODER:TY OWNERSHIP/AU
HORIZED AGENT
2.1 Owner Record:
Contact Addr s Phone Number
Name (print)
i
2.2 Authorized Agent:
Contact Address Phone Number
Name (print)
_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 CMRA 10.R6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Registration Number (if none, state "none"):
Company Name:
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
❑ 1 am a Homeowner performing all the work myself.
Name !�
Owners ( print):
Signature:. to the Guaranty Fund
be
y si g e above, the homeowner acknowledges that there will no eligibility
Date:
° 3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3- 5 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:
I ,
Signature: OS e n
ur signature carries ce ain responsibilities, including but not necessarily limited to, general liability
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT ;(MGL`c 152 § 25)
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provitde this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
I
SECTION 8 INSPECTOR'S REVIEW/COMMENTS RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13)
�25.00 APPLICATION FEE IS NON BI =FUNDABLE NON -TRANSFERABLE
u t w, =HATE RECEIV` D --
Date:�2
Date:
Date:
Date:
Date:
Date:';
1.1 Property Addre s �C/✓��,.`' f�'�`
\� Map Lot I -
Lot Area (sf.) Frontage
Required Provided
1.3 Historical District ❑ Yes ❑ No
16 _ Front Yard Has application been submitted to the Historic Commission?
Side Yard ❑ Yes ❑ No Date::
G�.
. Rear Yard
V N�-rl �h� (L1 J ors 1.5 wage Disposal System:
�QS C� �� 1.4 W er Supply (MGL c40 s54):
Cdn ❑ Municipal ❑ On Site Disposal System
Municipal ❑ Private W
c�1 ❑ CONSTRUCTION PLANS 0SITE PLAN 0 ENERGY REPORT