BP-41850RESIDENTIAL 2005
s` =SECTION 8 -INSPECTOR'S REV1E�'4'/CU14111IENTS
1. Date plan reviewed: !
2.30 days to review period expires:
3. OK to issue date: /z 3
4. OK to issue subject to requested submittals(see project review worksheet): Date:
5. DENIED (see project review
worksheet): Date:
6. HOLD
•—
reason: C r / Date:
7. HOLD subject to Zoning Board of Appeals action: / Date:
118. Comments: .� !> V ngSY _-z?7.o -.S -Iris e/- lag"-2 f r t
RESID
2005
❑ FOUNDATION ONLY
0 LICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
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RESMENTIAL
2005
RESIDENTIAL
:2005
a 1" ,NV
2.1 Owner of Record:
3
12C/
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
r CONSTRUCTION
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Constniction Supervisor
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Hom, Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section!
Are 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
i
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
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 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 dwelline, 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 un er this section sign w:
Signature: '
Your dignature/6#es certain responsibilities, including but not necessarily limited to, general liability
W
4'
Cot
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)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAYI" (hiGL 15�
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:❑ yes ❑!:no
all a licable
SECTIONS - DESCRIPTION OF PROPOSED WORK (check_
❑ new construction* ❑addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodsttove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolilfion
(shed/garage) no. of windows doors (specify below): (specify beylow):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit 1 no. of baths unit 1
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: 16 x ZC 5dr- ZX 4 CONS; QuG-rl o,-V Oil/ eRETE SLAPV
A F/?Aon � Roo F,
Item I Estimated Cost ($) to be completed by permit applicant
5.Total =(1+2+3+4)
(please print)
I,
to act on my behalf, in all matters relative to
Signature of Owner
* Estimated Total .1� $ j Coo . c` 0
of the subject property hereby authorize
Eby this building permit application.
Date
I, ✓1v / , ,tfl�i� ! J , as Owner/Authorized Agent hereby declare that the statements and informtation
on t oregoing applicationifife true and accurate, to the best of my knowledge and belief.
S}gned under the pains and penalties of perjury.
of Omer/Auer Orized Agent
Date
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