BP-11624Residential
1999
2.2 Authorized Agent:
Contact Address
�. l���T e/1/� ,/J�• � Telephone
. .. �f
A'�ame 'nt � !
�1
... .:::...
CAS C ....:SIt ...
\
is se Co structi Supery /
Not Applicable ❑
n truSu e
Licen c 0or
License b �@r
[�
Add es
Expiration Date
Signature °
3.2 Registered Home Impr ement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? es ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes
If yes, submit the required
affidavit!
Company Name
Registration Number (if none, state "none")
Address
Signature Telephone
Expiration Date
33 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
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.11 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
Homeowner sh 1 er-visor.
Homeownerengages a erson s fo r hire to do such work that suchshall act as super -visor.
section; provides that if a�P
sec( ) p
,P
n who owns a parcel of lam on which he/she
• Person(s) s d
the purposes of this section only, a .Homeowner Is defined as follows. P O p
...For
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 appl ' g under this section sign below:
Signature: A�J.
-
Your signakre carries certain responsibilities, including but not necessarily limited to, general liability
XD
Residential 1999
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. (she Appendix of 780
CMR R5.2.15)
Workers Compensation Ins
urance affidavit must be com
pleted and
submitted wi
th this application. Failur e
tto provide thlsaffiI davit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: *<es 10 no
.......::::.:...::...:: . .
::.:.::1t>n...n...lz.:.......::...:::::.....::.:..:::::...
❑ new addition ❑ alteration ❑ repairs ❑ chimney/firepla(ze ❑ 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:
Item Estimated Cost ($) to be completed by permit aipplicant
1. Building
(please print)
as Owner of the subject property hereby authorize�V r/t1J0/7 r�0 .
to a t on y behalf, in aIL4nallers relative to work authorized by this building permit application.
Siena re of Owner Date
:C.`i"isisi:>::3iSii:;?i:i:i:i::ii::i;:ii:ii:i . �. W. ?� .... �.... .
I r,. as Owner/Authorized Agent hereby declare that the stattements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
SignQd under the pai ps-and penalties of perjury.
Prirft Name - .41
Signature of Owner/Authorized Agent
Date
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Residential
1999
1. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue dater
4. OK to issue subject to requested submittals(see project review worksheet): Date:
5. DENIED (see project review worksheet): ' Date:
6. HOLD reason: Date'
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
r.
9. Inspector's Signature Dae�itf..
Applicant informed of Bove ate:
Continents: ;x
_ 7 Time:Clerk
or
Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balance: $;
TOTAL FEE: � �� Gross Area- New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To
MM
Residential ❑ FOUNDATION ONLY "
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20,
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