BP-43375SECTION 2- PROP El2NERSHIP/AUTHORIZED AGENT
2.1 Owner ;Record:
1
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
A
N me (priest)
Contact Address Phone Number
,.,, SECTION 3 = CONSTRUCTION SERVICES ,
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor. o& & 1 6 —
License Number: oil l
Address:
Expiration Date:
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Signature: �,,V-Gi Telephone�5 (p
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
`Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ Yes '12-60
_ If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
,
Company (Name: J (Ost-
Registration Number (if none, state "none" ): - ;
lIb`7
Address:
Signature: TelephoneSb I
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
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print):
r
Signature:,
By signing the above, the homeowner acknowledges that there will be no eligibility 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, by Construction Control in Section 116.0, effective July 1, 1982, no individual
shall be engaged in directly supervising persons engaged in con r, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
or structures„ unless he or she is licensed in accordan itfi the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
Supervisors.
Exception: Any Homeowner pertormin , r for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner
engages a pecson(s) for hire to do'cfi work, that such Homeowner shall act as supervisor:
For the purposes of this septen 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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there is, or is tntended�gt �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 E two,ydar period shall not be considered a Homeowner.
Doti are applying under this section sign below:
Signature:
,
Your signature carries certain responsibilities, including but not necessarily limited to, general liability _
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NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licenseod Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.,Z.15)
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure tolprovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Yes ® No
❑ Deck . ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pcsllet Stove
❑ New Construction" ❑ Accessory Bldg. ❑ Roofing/Siding J'�ther
(Energy report required) (Shed/Garage) (Specify below))
14 N iS /-I oa'v k"
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows _ Doors _ (Specify below))
"If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 0. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
❑ Furnace (hot air) -fuel gas (natural or propan , el oil, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or pr ne), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - prima natural gas, propane, electricity, other
❑ Air conditioning - (separat nit)
❑ None of the above a provided
❑ Hot Water: s Electric Fuel Oil Other
De ription of proposed work:?
Item Estimated Cost ($) to be completed by permit applicant;
1. Building>a�
2. Electrical.
3. Plumbing
4. Mechanical (HVAC) p
5. Total =(1+2+3+4) . ir 74 /sr.
(Please Print)
I, A n) J),e as Owner of the subject property hereby authorize 11m \hA14 r-n P 4A
to act on my behalf, in all matters relative to work authorized by this building permit application. S n
AJ�aI am 14A
Signature of Owner Date
I, My/P �44 as Owner/Authorized Agent hereby declare that the statements and mfformation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.'
Signa!yA of Owner/Au orized Agent Date
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: _ &I
Date:
Applicant informed of above: Date: 31XAi1 Time: 7 , oL6 Clerk:
Comments: V
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: `$ � � � � _
Other $ Amount $
TOTAL FEE: (� �' Gross Area - New Construction total sq. ft.�a�
Gross Area - Alteration total sq. ft. fir` -S �1 1-7-
Permit Issued to: __ l�u� // (1 Ye d dr C " a j yw 11 le, 1� 4� z- 77) ^
2? ��t✓i e�u4 C d'✓ +ice° is cr �`d`i ' rf l �za'.'
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE, &- NON.TnAT%TSFERABLE
and of Health: Signature: r 1,- t0_4AS-p A- Date:
nservation Commission: Signature: Date:
Other: Signature: Date: ,
Brief description of work being performed:
CONSTRUCTION PLANS 11 SITE PLAN EIENERGY REPORT