BP-62291Page 4
�® ❑ Approval in Part (Per 780 CMR.5111.13)
$25.00 APPLICATION IFEE IS NON ME -II ti"ABLE &
® C®NSTRUCTI®IV PLANS ®SI i E PLAN ENERGY REPORT
Page 1
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F SEGTtON 2 ,PicOPERT�Y t�WNERSHIPIAUTHORIZED
GE' T
2.1 Owner Record:
MCVZ'0 912e,1e
77.5 f o%405 &(t5 Q2a Sod' -Fq-q, its
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
:,.
, CONSTRtlCTIOIV,SERVIGES ,.... " ., = , , .. .:...,. .. ...... E...:, ..
3.1 Licensed Construction Supervisor/Specialty License : Lsl a32?0
License Number: (032A)
Company Name/Contractor Name: N �,ti , a .4
Address: ji (�i',ti �,�� . L ., Y 0
Expiration Date::
Signature: ,i ✓ Telephone: qol -37 =11S3
3.2 Regist ed Home Improvement Contractor:
Not Applicable ❑
Are you a dome Improvement Contractor subject to (780 CMR.110.R6)? TlYes ❑ No
Are you claming exemption from the requirements? ❑ Yes ❑ No
Yes, Go to Section 3.3
_``If
Company Name/Contractor Name: ocC ' cn cA ` tl
Registration Number (if none, state "none"):
Jt72
Address: 1
nQV��t
Signature: Telephone: 1-'T (
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
❑ I am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility 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
6108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no Individua
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building.
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 Constructioi
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 Homeowne
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 whit
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 tha
one home in a two-year period shall not be considered a Homeowner
If you are applying under this section sign below.
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration
❑ Chimney/Fireplace ❑//Woodstove/Peillet Stove
Zother
❑ New Construction* ❑ Accessory Bldg.
❑ Roofing/Siding
(Specify below)
(Energy report required) (Shed/Garage) _
❑ Addition ❑ Replacement window/door
❑ Demolition
,(Energy report required) No. of windows Doors
(Specify below)
*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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil
Other
Description of proposed work:
F aIL its 1,, hna
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
SECTION &.; ESTIIVIATEi3;;C�tSTRUGTION'GOST ',
Estimated Cost ($) to be completed t
Iola -to
I�Q
w
t1.100 .
Zrint) O-
`� e` a , as Owner of the subject property hereby authorize,r�i �.� (v-S�- 6^ � t�feS '�all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent hereby declare that the statements and informlation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury. _
Agent Date
*ignure`ofZ0'wner/Authorized
Page 3
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