BP-18804RESIDENTIAL 2000
SEC I i0 S 2� PROPE RTy' ONVINrtiSHIP l A UTHORiZEW,iG tT
2.1 Owner of Record: 5GO i tk,
4. 01aper l-1cr t e r- °i i 1- 6C,
Name (print): ` Contact Address Phone Number'
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
SEC 1141::: » E ONSTRiTC I It3N SER ICES :._:
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
PiERSONSCONTRACTING 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 l f4 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 Ho=owner 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 engkized 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 and '•
P�rP y, a Homeowner is defined as follows. Person(s) who owns a parcel land on which he/she resides or Intends to reside, on which
there is, or is: intended to be, a one or two familv dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two -}'ear period shall not be considered a Homeowner:
If}ou are ap 1�-ing rider this secti sign below:
Signature: VYl
Your signature carries certain responsibilities; including but not necessarily Iunited to, general liability
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Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provddfe this -affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: _ \6 yes ❑ no
;;:
- :;.»>.:... :. Si C fC(?I\ 5 nESGR1.PTI " . Choelk It .ai iea ` e
❑ new construction* ❑ addition ❑ alteration repairs c imney/ ❑J woodstove
(energy report required) (energy report required) fep a
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑I demolition
(shed/garage) no. of windows_ doors_ (specify below): (sfnecify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths -
Two Family: no. of bedrooms unit i no. of baths unit I
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 FuelOil - Other
Brief Description of Proposed Work: 4- , Yr—
r Z
1 5.Total=(1+2+3+4)
*Estimated Total $(?(j
(please print)
1, 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
as Owner/Authorized Agent hereby declare that the statements and ii'nformation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Si ne nder the pains and penalties of perjury.
t
Sign ure of Owner/Authorized Agent Date
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