BP-49719and Regulations section that an hicerised Construction
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules a Y
SBDE NTIAL
ervisor, whether or not they have taken: the permit are responsible for code compliance. (see Appendix of 780 CMIR R5 2.15)
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.. <.. Q AGENT . -:: -., .. .....
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- SECTION 2 -PROPERTY OWNERS
,. VIT MGL a 152 25 v....
SURANCE AFFIDA § )
-_ ;•. �_ -SECTION 4= WORKER S COMPENSATION IN (-
2.1 Ovn er Record:
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Worker'sCompensatlon'Insurance Affidavit must be completed and submitted with this application. Failure to provide a this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑Yes No
Name (print)
Contact Address - Phone Number
2.2 Authorized Agent.
WO Check all:a applicable) r�
SECTION S - QESCRIPTtON OF,PROPOSED W ( pp )
'
Name (punt) ,
Contact Address Phone Number
airs Re ❑Alteration ❑Chimney/Fireplace ❑ Woodstt'ove/Pellet Stove
❑Deck ❑Pool P
SECTION 3 -CONSTRUCTION SERVICES
❑ New Construction ❑Accessory Bldg.: ❑Roofing/Siding ❑Other
3.1 Licensed Construction Supervisor:
Not Applicable ❑
(Energy report required) (Shed/Garage) (Specifyj'below)
Construction S u ery iso r:
nst
Licensed Co p
License Number:
❑ Replacement window/door ❑ Demoliliion
Addition p
❑Add
(Specif, y'below)
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Expiration Date.
(Energy report required) No. of windows_ Doors _-
( 9Y p q )
Address.
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Signature: Telephone:
*If new construction, please complete the following:
3.2 Registered Home Improvement Contractor:
Not A licable ❑
PP
Single Family: No. of Bedrooms No. of Baths
Are ou a Home Im rovement Contractor subject to (780 CMR-6)? ❑ Yes ❑ No
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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 ❑ N o
No of Bedrooms Unit 2 No. of Baths Unit 2
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If Yes, submit the required affidavit!
❑Furnace (hot air) -fuel gas (natural or propane), fuel oil, electricity, other (specify):
Company Name.
Registration Number if none, state "none"): >
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) -primaryfuel; natural gas, propane, electricity, other
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Address:
❑ Air conditioning - (separate unit)
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Signature: Telephone:
Expiration Date:
❑None of the above to be provided
Fuel Other
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3.3 For Residential Remodel Work Only
❑ Hot Water: Gas Electric
Description Of pfOpOS@d work:�QthQ _ L �3f`� l
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
n Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
9 Home Improvement 9
ION
SECTION 6 - ESTIMATED .CONSTRUCT O m= _
I am a Homeowner performing all the work myself.
Item
J Estimated Cost ($) to be completed by permit aplplicant
1. Building
cs Name (print): : (2
Owners
2. Electrical
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3. Plumbing
Signature:
4. Mechanical (HVAC)
y sig ing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
5. Total = (1 +2 + 3 + 4)
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....,., ER AUl'H TION , _. v ,.. .... h
Date:
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m ermit.--.. .. .
completed when owner s agent or contractor applies for build _g,p )
(Please Print)
3.4 Homeowner Exemption - One & Two Family Only
I � , 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.
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
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shall be engaged in direct) supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
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or struck Tres, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
Slgna Ure of O er
Supervisors.
Homeowner he provisions of this section provides that if a Home
• work for which a Building Permit is required shall be exempt from t p , P
Exception. Any Homeowner performing o 9 q
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SE CTION 76=- OWNER/AUTHORIZED.AGENT DECLARATION
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
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one or two Tamil dwelling, or detached structures accessory to such use and/orfarm structures. A person who constructs more than
there is, or is intended to be, a Y 9
�{ i& � as Owner/Authorized Agent hereby declare that the statements, information
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 th's section sign Belo :
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Sig d under the pains and penalties of perjury.
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Signature:
Signature f Owner/Authorized Agent Date /
°" our signa' re carries certain responsibilities, including but not necessarily limited to, general liability
DATERECEIUyED
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1.1 Property Address: `� Cd MIX13 '(; ce) 1.2 Assessors Map & Lot Number:
Nearest Cross Street: l Jule 1W Map Lot ,-
Subdivision Name:
r, 1.3 Historical District ❑Yes ICI No
Total Land Area Sq. Feet: C.� Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
0 Municipal Private Well 0 Municipal XQn Site Disposal System
CO NSTRUCTION PLANS SITE PLA I N �� El ENERGY REPORT