BP-44480NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licerrised Construction
I
ESIDENTIAL -
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 2 -PROPERTY OWNERS / AUTHORIZED AGENT ..
= � ...:�:_ � PENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25): , , ,,. ` .•..:_
, ; _SECTION 4 r WORKER S COM a
?2.1
Owner Record:
i e -Yl �73 �(o 3Ca � 23
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide thins
Phone Number
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑Yes ❑ Nfj
Contact Address
ame (print)
Authorized Agent: _
2.2 9
; ,.SECTION 5 -;DESCRIPTION,` OF PROPOSED WORK Check all a licable '
'
Int
Name (print) r
Contact Address Phone Number
❑ Deck ❑ Pool ❑Repairs ❑Alteration ❑Chimney/Fireplace ❑ Woodstove//Pellet Stove
.. SECTION 3 -CONS TRUCTIONSERVICES
Construction* D Accessory Bldg. ❑ Roofing/Siding ❑Other
❑ New Constr
3.1 Licensed Construction Supervisor.
Not Applicable ❑
(Energy report required) (Shed/Garage) (Specifybellow)
•-
Licensed Construction Supervisor:
License Number:
❑Addition ❑Replacementwindowldoor ❑Demolition;
(Specify be)row)
"
Expiration Date:
(Energy report required) No. of windows _ Doors
0
Address:
W
Signature: Telephone:
*If new construction, please complete the following:
Z
3.2 Re4istered Home Improvement Contractor: -
Not Applicable ❑
W
Single Family: No. of Bedrooms No. of Baths
9
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
Are you claming exemption from the requirements? ❑Yes: ❑ No
No of Bedrooms Unit 2 No. of Baths Unit 2
If Yes, submit the required affidavit!
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
Registration Number (if none, state "none"):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
IL
Company Name:
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
®
Address:
❑ Air conditioning - (separate unit)
Signature: Telephoner
Expiration Date:
❑None of the above to be provided
Electric Fuel Oil Other
❑ Hot Water. Gas
3.3 Far Residential Remodel Work Only
CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
Description Of proposed work:
PERSONS CONTRACTING WITH UNREGISTERED
2 rUGI< n
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QUESTIONS OR COMPLAINTS call or write.
n Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
Home Improvement 9
CTION ESTIMATED CONSTRUCTION COST '.> ..
t
Item
Estimated Cost ($) to be completed by permit applimant
❑ I am a Homeowner performing all the work myself.
1. Building
Owners Name (print):
2. Electrical
a
3. Plumbing
4. Mechanical (HVAC)
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
5. Total = (1 + 2 + 3 + 4)
Da
WX�ITHORIZATION ..
{ N :7A - O.
„ w SECTIO
=: ,m
agent or contractorapplres for builtlmg permit)= �^ � •
.
(to be completed when`owner•s
(Please Print)
ner Ex m tion - One & Two Family Only
3.4 Homeowner p
j , as Owner of the subject property hereby authorize_ -
to act on my behalf, in all matters relative to work authorized by this building permit applicati0na�
T PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
OR HOMEOWNERS WHO INTEND O
109.1-1 Licensing of onstruction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
involving the structural elements of buildings
.
shall berengaged in ' ectly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition
Date
he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
jgnature Of Owner
o rueures, ss
Supervisors. Homeowner
provisions of this section; provides that if a o
h Building Permit is required shall be exempt from the p p
Excep.�on: Any Homeowner performing work for whir. a g q
' ,r ; •'SECTION 713 - OWNER/AUTHORIZEID. AGENT DECLARATION,
engages aperson(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
structures accessory to such use and/or farm structures. A person who constructs more than
i
el J P as Owner/Authorized Agent hereby declare that the statements artfd information
there is, or is intended to be, a one or two family dwelling, attached or detached
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one home in a two-year period shall not be considered a Homeowner.
on the foregoing application are true and accurate, to the best of my knowledge and belief.
If you are applying under this section sign below:
Sign der the pains and penalties of perjury.
/ /C
5
Signature: liability
general liab
to 'I limited X
rily din but . 9
' not necessa
i ies in Y
s ons ibrl t
m re 9
certain
Your signature carves cep
rized A e nt Date
Signature o cane , utho g
El SPECIAL PERMIT (Per 780 CMR 111.13)
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: bae lejz. ��'-e'��� � r L� Date:
Applicant informed of above D te: / Time: v Clerk:
Comments: a)X -
i
Less Application Fee. $25.00 Remaining Balance: $
Total Permit Fee: a �A
Other $ Amount $
TOTAL FEE: Gross Area -New Construction total sq. ft. A, -'A —
Gross Area- Alteration total sq. ft.
Permit Issued to: x
L,2 2
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