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BP-40342RESIDENTIAL RESIDENTIAL 2.1Owner of Record: g' Name (print) Contact Address Phone Number 2.2 Authorized Agent: 17 A IName (print) Contact r Phone Number 3.1 Licensed Construction Supervisor: Not Applicable ❑ -Licensed Construction Supervisor - " ��� License Number Address ' Expiration Date Signature - Telephoneb-D<� .4 3.2 Registered Home Improvement Contractor Not Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ If no, go to the next section! Are you claiming exemption from the requirement? ❑ yes ❑ no If yes, submit the required affidavit! Company Name Registration Number (if none, state "none") Address 1, 1 0 W% Lj' V Signature TelephoneS-()195FExpiration Date'; 11 3.3 For Residential Remodel Work Only PERSONS CONTRACTING wrrH 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 sigtung the above, thAome 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-0R'N PROJECT - - 109.1.1 Licensing of Construction Supervisors: Except for thosstructures 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 ofbuildings or structures, unless he or she is licensed in acc=for 16the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction Supervisors. t Exception: Any Homeowner performingi h 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 sur h ork, that such hom(�wner shall act as supervisor. For the purposes of this sectio�,Pffly, 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, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-yearperiodshall not be considered a Homeowner. If you are applyin (znder this section sign below: - Signature Your signature carries certain responsibilities, including but not necessarily limited to, general liability NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licenseed Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR FZ5.2,15) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failuret oj 1provide this"/ affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attacked: ®'yes ❑ n o new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove rgy report required) (energy report required) fireplace F;eck❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition (shed/garage) no. of windows doors (specify below): (specify 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 Work: . _ Item Estimated Cost (S) to be completed by permit appllicant ' 1. Building 2. Electrical Plumbin 4. Mechanical HVAC 5. Total = (1 + 2 + 3 + 4) *Estimated Total $ (p Spn - I, as Owner of the subject property hereby authorize �,,/✓ to act on my behialf, in all matter . 1 five to work authorized by this building permit application.CLVJ ' r t © — r. Signature of Owner Date I,MqtCAM 'U� L ,,t , as Owner/Authorized Agent hereby declare that the statements and information on t e foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Agent .Date 0:\bldg. forms\B ldgapp.res.wpd Page 2 Rev. January 2005 C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January 2005 I; RESIDENTIAL ' RESIDENTIAL l . Date plan reviewed: 7 workneet}: Date:` E� 4v 3. HOLD ; reason: Date: 4. HOLD subject to Zoning Board of Appeals action: Date: APPLICATIC Comments: fCi I ,SS SG Ui11R TY flFOi'LOWItV+GAB' Mkki f Insp ctor's Signature Date' ;.'.;, INC}TIFIG1IOl�r/ .:� r yiM Applicant Informed of ahove ate: 4 Time: Clerk: Comments: C7 Iic�arcl t � i Boy Ape�als� t���afl 1 'M W f �.�9it`F - . ;/. .... i tI4� SPCO • Total Perrnit Fee: $ �U Less Application Fee: $ 25.00 _ Remaining Balance: TCiTriL FEE: ,00 Gross Area - New Construction total sq. ft.� �ARM ` Gross Area - Alteration total sq. ft. ❑ FOUND,MoN ONLY