BP-50295SECTION 8 - INSPECTOR'S REVIEWIGOMMENTS -
❑ SPECIAL PERMIT (Per 780 CMR 111.13) .
1 nnto ninn roviowor!• .825.00 APP1.1+d"AV19l-T Vir, W iQ xlshw ■iw 1v.T7%,Tn.a eai
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DEPARTMENTAL APPROVAL .
Zoning Review: Signature:)
Date: vJ
Energy Report: Signature: Date:
Fire Chief: Si nature: Date:
Board of Health: gnature: bate:
Conservation Commission: Signature: - Date:
Other: Signature: Date:
Brief description of work being performed: PL L _ -?a yv a O
1.3 Historical District ❑ Yes 4J40
Total Land Area Sq. Feet: Has application been submitted to the Historic Clommission?
/ ❑ Yes ❑ No Date:
/4 Wat r Supply (MGL c40 s54): 'gage Disposal System:
'Municipal ❑ Private Well
Municipal ❑ On Site Disposal Systtem
❑ CONSTRUCTION PLANS SITE PLAN ❑ ENERGY
.� G REPORT
RCS1DEdTIAL� NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulatio
ns section that any licensed Construction
'SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
M�Q) i�u���
qn /� 3�d� 720 jog/
,
/Name (print
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 CONSTRUCTION SERVICES
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 claming exemption from the requirements? ❑ 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
�I Homeowner
am a performing all the work myself.
P 9 Y
Owners Name (print): 1 V
Signature:
By signina t6e a ove, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date: L4 07-0
s �
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 direC:!y supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
or structures, unless he ar 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 o 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 all not be considered a Homeowner.
If you are lyinn er this section sign below:
Signature: Y�, ��
o r signat6feelcarries certain responsibilities, including but not necessarily limited to, general liability
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 4 -WORKER'S COMPENSATION INSURANCE AFFIDAVIT'(MGL c"152 § 25)
Worker's 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
SECTION 5 -'DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stclve
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ 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:
� '"• ° .- SECTION 6 ,- ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
--5 0,00
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
/
5 Total =0+2+3+4)
SECTION 7A - OWNER AUTHORIZATION
(to be con t completedowner's'agent or contractor applies for buildingpermit) �'
.when
(Please Print)
, ) , as Owner of the subject property hereby authorize
k
0,46t on my behalf, in all matters relative to work authorized by this building permit application�=
Signature of Owner Date
SECTION 713-`OWNER/AUTHORIZED AGENT DECLARATION
I, J `— L—k 777 as Owner/Authorized Agent hereby declare that the statements and informatiron
n the foregoing application are true and accurate, to the best of my knowledge and belief.
the pains and penalties of perjury.
VSigneunder
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v�
ignatur of O er/Authorized Agent Date
' DRI
DISCHARGE TO
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