BP-110631999
Residential
2.2 Authorized Agent:
Contact Address d,<— j4,L)Lr—
/®,,�
Name (print) ® --)'-7 Telephone
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1ttJ 1. 51...............................:..................
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3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor License Number
Address Expiration Date
Signature Telephone
3.2 Registered Home ImprovementContractor: Not Applicable
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes 0 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")
I
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 above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4jHomeowner 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 be considered
a Homeowner. 0L.- &_01- �110�)
If you are applying under this section sign below:
Signature:
Your signature carries certain responsibilities; including but not necessarily limited to, general liability
c:hvpwin\forms\bldgapp.res Page 2 January 20, 1999
Residential 1999
NOTICE To LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section tlbat any licensed
Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (ee Appendix of 780
CMR R5.2.15)
_ Workers Compensation Insurance affidavit
davrt must be completed and submitted with thi
s apphe alton. Failure-, t o
provide thi
s af
fidavit davit-
Signed Af
fidavit
avlt Attac
hed: Dyes n
t Y
will result in the dental of the Issuance of the building permit. g
. -- _.. ......
❑ new ❑ addition ❑ alteration ❑ repairs ❑chimney/fireplzace ❑ woodstove
construction*
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows_ doors_ (specify below): (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
Brief Description of Proposed Work:
a0
::: :::.. ,�.::. :.. .: v.,... ....'iix+fi'cl+a�11'fSi'1!i`Ii�iltvi: %l4"!`C`i::
1vA as Owner/Authorized Agent hereby declare that the stmtements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury
C,
Print r3ahke
Signa re -of Owner/Authorized Agent Date
c:\wpwin\forms\bldgapp.res Page 3 January 20, 1999
Applicant informed of ab ve Date* I 1 Time: AV'61 Z!L/7 Ierk �
Comments:_
Total Pernnit Fee: $ �� ` I Less Application Fee: $ 25.00
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To_—
Remaining Balance: $ c'v
Residential FOUIVDATlON ONLY 1999
c:\wpwin\forms\bldgapp.res Page 1 JJanuary 20, 1999