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RESIDENTIAL 2004
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2.1 Owner of Record:
Cr(, c, -+DJ , "be M-eIto 5'�U!//S%G✓J 4-40i�
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Contact Address Phone Number
Name (print)
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3.1 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 a Home Improvement Contractor subject to (780 CMR-6)? e"yes ❑ no
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
Signature Telephone Expiration Date
t
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, t Jome owner acknwledges Lhatthere, owill be no eligibilty to the Guaranty Fund
Date �t o
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 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 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, 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-year period shall not be considered a Homeowner.
If you are applying and his section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL 2004
FNOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
u ervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
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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
❑ new construction* El addition
t�eration ❑ repairs ❑ chimney/ �'woodstove
(energy report required) (energy report required)
fireplace
❑ deck ❑ pool ❑ accessory bldg.
❑ replacement window/door ❑ other ❑; (demolition
(shed/garage)
no. of windows_ doors_ (specify below): (sR)ecify 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: 1.,,,,--Fz{,, , J 7,) e i 0t ►@Per" e .^i to g i2fr[< <^'i Pi ") �? 4 e %t.uv t C,
Item I Estimated Cost ($) to be completed by permit applicantt
Signature of Owner
Date
1 � t-*3e,t,lc-l& , as Owner/Authorized Agent hereby declare that the statements amd information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury. ��
/ .� -,,-A )-, ."/, Cam�?1U/e-/
Signature of Owner/Authorized Agent
DPube
Page 2 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd
Page 3 Rev. January, 2003
RESIDENTIAL ❑ FOUNDATION ONLY 2004
$25.00 APPLICATION FEE IS NON-REFUNDABLE ac NON -TRANSFERABLE
RESIDENTIAL 2Z004
FOUNDATION ONLY
❑
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
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:
8.
Comments:
9. Inspector's Signature:
Applicant informed of above
Date: l - l Timeg, %_5 Clerk:-
7 -7, V" r+ `4- ter'_ L r, 11�
Total Permit Fee: $ / /Cl • UJ J I Less Application Fee: $ 25.00
TOTAL FEE:,/0, 00 Gross Area - New Construction total sq.
Gross� Area �. Alteration total sq. ft.__7
e
Remaining Balance: $ 0 J '
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CAb1dg.f6rms\B1dgapp.res.wpd Page 4 Rev. January 1, 2003
CAb1dg.forms\B1dgapp.res.wpd Page 1 Rev. Januaryy 1, 2003