BP-617972.1 Owner Record:
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
�... , :�, SECT[L3I 3 GO[STRUG t ION SERVIGESp '�� w
,r
3.1 Licensed Construction Supervisor/Specialty License : License Number:
Company nrame/Contractor Name:
Address: `
Expiration Date:
Signature: Telephone: `
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.136)? ❑ Yes ❑ No
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, Go to Section 3.3
Company Name/Contractor 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:
Hame Improvement Contractors Registration, One Ashburton Place - Room 1301; Boston, MA; 02108, 617-727-8598 _
❑ I am a Homeowner performing all the work myself.
Owners Name (pri ): 3l
I
Signature:`
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund ,
Date: A'
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT ,
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building
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 Constructioi
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 Homeowne
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 whic
there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/orfarm structures. A person who constructs more tha
one home in a two-year period shall not be considered a Homeowner
If you are apprying under this s to sign ow:
-Signature:
ur signature carries e n responsibilities, including but not necessarily' limited to, general liability,
Page 2
Page 3
3. HOLD
Reason: Date:
� 4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
_.
AN *z ,n-,_,- hxn,,< �'r+
m
Inspector's Signature: Date. 1 �" a.,. , m , _>„� _ ., ., _ .. 'i s:: _ as -•r� � _ av , .:... „art „ ,...., , a m,., r >�.:'.,>�. >,r�:.< , ?.F�« ,.. DAn T.E, .M,.,I: SSU<E,� D.
_ �.. _..
�», is ,w a. ,... _., ,, �.✓. `�, c':, ,,. a <.,_ �._. �: '3 .. ,. _
.. , <.,
a
�
,..:w
® above: Dat.,. Time. Clerk.
Applicant informed f ab
PP
_
._... _...,,.:a ,...:'>.. ., a .. ,. , ... .. ... w .'� __. .. <,r... .�„ .. 1. .. coma
5 , ,. , fit. .. _, >,.x ,_ ,,, .:,.. ,.�' .,, ,� ,r .. _ � ,..,... _. >F.,,
.. ,v Yg .-,... ,. a�3 ;D. ... ,ti'?G` .....a ,., .:. ....�. ;, .,_,. -: ,. _. > ,,:... ..e.. ,... , .. ...,.G...... ,,.. ,, e ,
arm_
Comments: a.,
Zon�nDi fc�ci_< ��-
s ..
. - ,., < ...-. _.... u
.,....-
.,
< .>..,,.. n:._. .. ,rT ._.. r, ,s .,.., k ,;.w,f .. <..;� "nr Y ',,. •; .'X a:..,.,. r. .,._ .: ...r x --. `,
B
Less Application Fee. 25.00 Remaining glance. � �
Total ermit Fee. $ _ .< ,� _� � _.-. »_ _.
_ QZ < II UVater Goa �.
�Card <>: ..
LhPann
Ocher Amount N..m � > _ ,� ,.
ti , Baarct.: . Cut,:Cff» ,..Gut., f€
� 9
�...a_,.,,
— � » � IaEQUIRES Ii�ISPEC�TU
»....
w Construction totals .
L EE. Gross Area New Constru t
TOTA F 9 � ,»d» � , �.� ; � �� ; `� , » . � � .:. F ... < O1FAI_� .. ,•: � -�:
Gross Area - Alteration total sq. ft.,..,.
Zoning Review: Signatur Date:'
Permit Issued to: _
1(J9 Energy Report: Signature: Date:
Fire Chief: Signature: Date:
. ...._
__.
Date.
.KEG
_.,....__.a Board of Health. Signature.
Conservation Commission:' Signature: Date:
�.� .. Other. Signature: Date:
Brief description of work being performed:
�"''��), L oust
.. .... . �,.... .... ..._ .. _. 1. ....
FflI2MA.. � �te� �, .a-.,.--��_
>a>S , �v'.:F
1.1 Property Address: 1.2 Assessors Map & Lot Number:
$,
Lot Area (sf) ` Frontage Map `—"-- Lot17
-
,Required Provided
✓ Front Yard 1.3 Historical District ❑ Yes ❑ No
3.25. Side Yard Year Built.
Rear Yard
_
❑ Altering more than 25°/a per side of building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commissiocn?
❑ Municipal ❑Private Well ❑Municipal ❑ On Site Disposal System ❑Yes ❑ No Date:
CONSTRUCTION LA SITE PLAN ENERGY �§
.Page 4
Pagel (