BP-41561� �Q5
t ewe !, IN
0
tgj
Sd
' G7 N uj #1
a
Lu
00
2`)LLJ
rt. .
� 3
t'4} LL:
600
a' y
h^3
>_
r C)
aLi tat {�
\`
V):� >
`q'
��
00
AN
i
CJ
o
w
4
CQ
•
f
04
sm
o
nee
2005
1V—uvaA-01 J".L.
- T 1
,.
2.1 Ow>aer of Record:
j
7 l— Z-0 `
Z-V-43--,
Name (print)
ontact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
N
-STR3.1
l
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 n Home Improvement Contractorsubject to (780 CMR-6)? ❑ yes ❑ no
If no, go to the next section!
Are youclaiming exemption from the requirement? ❑ 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
Owners Name (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibiity 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 -ovemed 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
there is, oris intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constlucts more than
one home, in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
ur signature certain onsibilities, including but not necessarily limited to, general liability
C:\bldg.fo=s\Bldgapp.res.wpd Page 2 Rev. June 26, 2003
RESIDENTIAL
ides in the Rules and Regulations section that any licensed Construction
NOTICE TO LICENSED CONTRACTORS: The Building Code provides g
k the pen -nit responsible onsible for code compliance. (see Appendix of 780 CMR R5.2.15)
Supervisor, whether or not they have toen e p
77,
";SECTION"4 -`WORKER'S COl`r'TPENSATION INSURANCE,AFFIDAYITW(M , ,"
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 «'ORK (check all applicable}
._
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑, wroodstove
(energy r d report required) fireplace
(energy report requlrerl) ( �' ' e P 9 �
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ dl;emolition
(shed/garage) no. of windows_ doors_ (specify below): (spe6fy 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
Brief Description of Proposed hVork: -
SECTION'',' 6;ESTIMATED,CONSTRCICTION COSTS '', . a , .
Item Estimated Cost ($) to be completed by permit applicant
1. Bulldlnn
2. Elechical
3. Plumbing
4. Mechanical HVAC '
* Estimated Total$ -, 67eO
!l O
5.Total =(1+2+3+4)
(please print)
I as Owner of the subject property hereby authorize
to act on my behalf, in all matters relati e o authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent hereby declare that the statements andl information
Vone foregoing application are true and accurate, to the best of my knowledge and belief.
Signe under the pains and penalties of perjury.
Data
Signature of Owner/Authorized Agent
C:\bldg. forms\Bldgapp.res.wpd
_Page 3 Rev. June 26, 2003
RESIDENTIAI. 2005
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:
S. Comments:
9. Inspector's Signature:/ ���
Date: 6
Applicant inform d f above te: �h %(� %' Time: �clerl/'
Comments: IV
t ,
Total Permit Fee: $ f Q Less Application Fee: $`25.00 Remaining Balance: $zl::21 _ 00
TOTAL FEE: �' S 1 6 0 Gross Area - New Construction total sq. ft.
Gross Area =Alteration total
sq. ft.
Permit Issued To- Q rr 14C&ff 0
Page 1 Rev. June 26, 20M