BP-50944SE_CTION `8 - INSPECTOR'S REVIEWICOMMENTS ,
`
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD
Date:
I.
Reason: Date:
4. HOLD subject to Zoning Board o fAppealsaction;
Comments:
III
Date:
Inspector's Signature:
.,
SECsTION 9 - APPLICANT NOTIFICATION
. _ Clerk:
Applicant informed of above: Date: Time:
Comments:
i"
„.
ECTION" 10 =OFFICE/INSPECTOR'S; NOTES
Less Application Fee: !'�
Remaining Balance: $ V
Total Permit Fee: $ 7�G6
Other $ Amount $
0�
Gross Area - New Construction total sq. ft.
FTOTALFEE:��
Gross Area - Alteration total sq. ft.
o: /�h L
S ! ' /y 9, 7� t �✓ /�Q __ -
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES ;
is
V
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
SECTION 1 -SITE INFORMATION
NOTI
CE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any Iicerised Construction
Super
visor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR RCS 2 15)
RESIDENTIAL RFHIP/AUTHORIZED AGENT
CE'AFFIDAVIT MGL c 152 §
SECTION 2 -PROPERTY QWNE h " SECTION 4 = WORKER'S'GOMPENSATION INSURAN
2.1 Owner Record: _ Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide thiis
T SSE. ��S ulf�- r of the building permit. Signed Affidavit Attached: ❑ Yes ❑ Nro
�..� � � U Phone Number affidavit will result m the denial of the Issuance 9
® Address
Contac
t
e (print)
w SECTION 5 - DESCRIpI ION:OF PROPOSED WORK"(Check all a licable
2.2 Authorized Agent:
over llet Stove
Phone Number /Pe
� Contact Address ❑Deck ❑Pool ❑Repairs ❑Alteration ❑Chimney/Fireplace ❑ Woodst
Name (print)
3 = CONSTRUCTION SERVICES ; 4 ❑ Accessory Bldg. fil'Roofing�e iding ❑ Other
SECTION ,
� ❑New Construction* ry l
(Specify bellow)
Not Applicable ❑ (Energy report required) (Shed/Garage)
3.1 Licensed Construction Supervisor: /
License Number. lll4teplacementwin ow/door ❑Demolition,
Licensed Construction Supervisor. ❑ Addition (Specify below)
�.., Expiration Date: (Energy report required) No. of windows Doors
Address:
Telephone:
! *If new construction, please complete the following:
Not Applicable ❑
Z 3.2 Registered Home Improvement Contractor:
W Single Family: No. of Bedrooms No. of Baths
{ Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑Yes ❑ No
® If No, go to the next section! Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
...1 claming exemption from the requirements? ❑ Yes ❑ No No of Bedrooms Unit 2 No. of Baths Unit 2
LL Are you c g exem P
If Yes, submit the required affidavit! ❑Furnace (hot air) -.fuel gas (natural or propane), fuel oil, electricity, other (specify):
o Registration Number (if none, state "none"): ❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
Company Name: LiL) 5/� t
❑ HVAC (combined unit) -primary fuel, natural gas, propane, electricity, other
'� I Si P)
❑Air conditioning - (separate unit)
L® Address:
__. � ® ❑ None of the above to be provided
� � S Telephone"��? �I�1 � � � Expiration Date: Fuel Oil Other
Signature: ❑ Hot Water: Gas Electric
3.3 For Residential Remodel Work Only
� WITH UNREGISTERED CONTRACTORS TO THE GUARANTY FUND: Description Of pPOpOS@d work:
PERSONS CONTRACTING WI ACTORS DO NOT HAVE ACCESS r
QUESTIONS OR COMPLAINTS call or write: ton MA 02108, 617-727-8598
n One Ashburton Place -Room 1301, Boston, ON CO
Home Improve Contractors Regrstraho , „ ;;; k SECTlON.6 -ESTIMATED CONSTRUCTI
Ho p
7 t.... ,
,
❑ I Item Estimated Cost ($) to be completed by permit appliicant
am a Homeowner performing all the work myself.
1. Building
"" a 2. Electrical
Owners Name (print):.'_ < _ .
. 3 Plumbing
,
4. Mechanic VAC ( )
Signature: fi . _.
meowner acknowledges that there will be no eligibility to the Guaranty Fund 5. Total = (1 + 2 + 3 + 4)
R s ninq tfie above, the ho _ ORIZATION
y g N 7A ''"OWNER;A
.. -, r SECTIO -
k
., ....
ontractor appl fes forpulld_m_ g peagent orcDatermtt
r
) ^•_ • • "= -" •
(Please Print)
3.4 Homeowner Exemption - One & Two Family Only I S = C0 �� as Owner of the subject property hereby authorize
PROJECT to a my behalf, in all matters relative to work authorized by this building permit application.
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJ
t for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
909.9.1 Licensing of Construction Supernsors: Except
shall be engaged in directly supervising ervisin persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings r - Date
p 9
or structures, unless he or she is licensed imaccordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction Signature,?f11 ner
Supers isors a provisions of this secfion, provides t hat if a Homeowner RATION , i__„
Permit is required shall be exempt from the p SECTION 7B - OWNER/AUTHORIZED AGENT DECLA
Exception: Any Homeowner performing work for which a Building Pem7
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor. n which he/she resides or intends to reside, on which
For the purposes of this section only, a "Homeowner" is defined as follows: Persons) who owns a parcel of land o A person who constructs more than as Owner/Authorized Agent hereby declare that the Statements arnd information
P P
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 p
one home In a two-year Period shall not be considered a Homeowner. on foregoing application are true and accurate, to the best of my knowledge and belief.
If you are applying under this section sign below: Signed under the pains and penalties of perjury.
Si rtature: eneral iiabilit a Date
Sig
mature:
signature carries certain responsibilities, including but not necessarily limited to, g y Sign ure of r wner/A It thorizred Age
-�