BP-20234RESIDENTIAL
2001
SECTION 2 -PROPERTY OWNERSHIP AUTHORIZED AGENT
2.1 Owner of Record:
<`/ 76"
S`"6 P#eA/ K`` c14&
l'9 t,)WIJ-C61Zf WAig
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: PGOL, < 1, eyft2,_(,_M61 U,,fCIA46,Not
Applicable ❑
Licensed Construction Supervisor
License Number
Address 6 5o 6/4 < . *Lu
Expiration Date
Signature Telephone Ill —e 33 Z
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!
Q
Company Name i DO L5 .E- cuatS oj'o.-s (1t u G=
Registration Number (if none, state "none")
Address S71 CA A, H WV rZ_'C a
Signature Telephone' 33
Expiration Date -
3.3 EFor Residential Remodel Work Only,
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or writer
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
109.1.1 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 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 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 they is, or is intended to be, a one or two family dwellin¢, 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 z-::pplying under this ction si below:
c
Signature:.
our signa ure carries certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL 2001
NOTICE TO LICENSED CONTRACTORS:
The Building Code provides in the Rules and Regulations section that any licensed Constrruction
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)
Workers 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)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ U woodstove
(energy report required) (energy report required) fireplace
❑ deck XPool 0 accessory bldg. ❑ replacement window/door ❑ other m demolition
(shed/garage) no. of windows doors (specify below): (sppecify 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 (specify):
❑ " Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
r
Brief Description of Proposed Work: .,,711�%✓ G6 ! 9OU416
Po
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant:
1. Buildinizo
-
2. Electrical
�✓'d P
3. Plumbiniz
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Totalj�4 .
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print)
I, SMCPaON K CT C, UI, , as Owner of the subject property hereby authorize ea L
to act on m al in all ���ive to work authorized by this building permit application.
Signature of Owner , Date
ECTION 713 - OWNER AUTHORIZED AGENT DECLARATION
I, 5 2r/46/ J K rr(, 4r/A( , as Owner/Authorized Agent hereby declare that the statements anrd information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of per'ury.
Signature of Owner/Authorized Agent Date
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RESIDENTIAL
2001
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue date`.
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:
Date:
8. Comments:
9. Inspector's Signature:
2
1 SECTION 9 - APPLICANT NOTIFICATI N
Applicant informed f above Date:) Ti ' me: Clerk•
_ a,
Comments: 4 ,
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fe: $
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 _
SECTION I I —ADDITIONAL COMMENTS/SKETCHES
�- .r�d�� der-�'9 i�i � _ _ _ _ •- -. �
C:\bldg.forms\Bldgapp Tes.wpd Page 4 Rev. January 19, 2001
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ ves ❑ no
1.2 Assessors IV
Numbe
1.1 Property Address: L J d,4LC 1z c S LJ,o1-/
Plat Lot
Nearest Cross Street: -F/ S 9"L
Subdivision Name: 1.3 Historical District ❑ yes ❑ no
Total Land Area Sq. Ft.: Has application been submitted to the Historic Commirssion?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ MunicipaPA
Private Well ❑ Municipal On Site Disposal S,j,stem
�7
C.\bldg.forms\Bldgapp.res.wpd Page 1 Rev. Janua ; 2
! r y 19, 001