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BP-34441RESIDENTIAL 2004 RESIDENTIAL 2004 ❑ FOUNDATION ONLY ❑ FOUNDATION ONLY `'`` $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE �MON INSPECTOR � R VIEWIC©i�1 N � 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): 5. DENIED (see project review worksheet): 6. HOLD reason: Date: Date: Date: 7. HOLD subject to Zoning Board of Appeals action: 8. Comments: Date: 9. Inspector's Signature: ate: 2004 AU E TI® NOTIFICATIQN p NN 4of ® Applicant informed above Dat Time: Comments; Clerk: SECTION 0 OFFI( EVNSP 1 flR'S NOTE 0- 6 . . .... Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balance: $ cy TOTAL FEE: � Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. r ,� / Permit Issued To: �Y � 3G .e ✓ 11�� 6 / �r " ECTION 11 z I?DIT ONAI< 0MMENT %$KET m _ ��.� No z 0Nivtuiut;ipai rnvate well p.�viumcipal u un Nite Jiisposail System CAbldg.forms\Rldgapp.res.wpd Page 4 Rev. January 1, 2003 CAb1dg.forms\B1dgapp.res.wpd Page 1 Rev. JJanuary 1, 2003 RESIDENTIAL 2004 RESIDENTIAL 200-4 r , �w ���®.� s mMmw .e.. .A ..... .: ... 2.1 Owner of Record: 2R, q aV -3 .� Name (print) Contact Address Phone Number 2.2 Authorized Agent: tee` `� Contact Address Phone Number E`" Name (print) a d® Fmk p . ' 01 -� � UZ l�C ®ems m x h La:-- 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! 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 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 ove, he home XWner acknowledges th t the e-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 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 considered a Homeowner. If you are applyi r this sec - n si belo Signature: Your i afore carries certain r sp sibilities, including but not necessarily limited to, general liability 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) 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 ❑ new construction* ❑ addition (energy report required) (energy report required) ❑ deck pool! ❑ accessory bldg. (shed/garage) * If new construction, please complete the following: ❑ alteration ❑ repairs ❑ replacement window/door no. of windows_ doors_ 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: _Zr V -P�) P�j j _ ❑ chimney/ fireplace ❑ other (specify below): ❑ woodstove ❑ demolition (specify below): Item Estimated Cost ($) to be completed by permit applicant 1 Rnilrlina 7 F1Prtriral i Plnmhina d MPrhnnirnl (HVAC) 5. Total = (1 + 2 + 3 + 4) * Estimated Total $ (please-:nt �� , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I4D6- %W as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties-�erjury. of Agent Date C:\bldg.fonns\Bldgapp.res.wpd Page 2 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January 1, 20t03