BP-2005-40082i2 F CTiIFNTT A T
:ESIDENTIAL
IN
�.,�.,.
12 Owner of Record: -
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7poc&ee
Name (pr:nt) Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
a IN
:
ll,.. E -TWO
_ C.
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!
Arc you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
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:
QUESTIGNS_OR COMPLAINTS call or write:
Home Jnprovement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
'
Owners Name (print' of z
S i up atu
y signs. g the at- e, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4 Horneowner Exemption - One'& Two Family Only
FOR HOMEOWNERS WHO NTEND 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 supervisingpersons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements ofbuild:ngs
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 bo 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 s' bel
Signature°
Y ur signatur c r :m responsibilities, including but not necessarily limited to, general liability
Item Estimated Cost ($) to be completed by permit applicant
1. Building- -
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sz�
S' 77
1.
Date plan reviewed:
2.
DENIED (see project review
-
Date:
3.
HOLD
rearson.
"um
Date:
A
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RESIDE TI�-
$�5.00 APPLICATI,
❑ FOUNDATION GA '_-',! F
IS 1 ON—REFUNDABU & 3aIIIlOT=TRAAiSFEiIAMALE
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