BP-01RESIDENTIAL
2001
2.1 Owner,4 Record:
r
de)j�
1
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
t '" V �l
�)� ,
Name (print) Contact Addy
Phone Number
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 1K
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes Kno
If no, go to the next section!
Are you claiming exemption from the requirement? 0 yes ❑ no
If yes, submit the t
required affidavit! ;
Company Name Registration Number (if none, state "none")
Address
Signature Telephone Expiration Date
3.3 For Residential
es antral Remod
el Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO. NOS' HCCESS 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)
t3 gnature
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
3.4 H - .
Homeo
wner Exemption One &Two P Family Onl
Y Y
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 Lieenslmg 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 Homeow ner rs define
d as follo
ws:
s. Person(s
) whoowns
s a parcel of land on which he/she resides or intends to re • de, on
which there is, or is intended to be, a one or two family dwelling, attached si
ordetached structures accessory to such use and/or farm structures. A person who constructiss
more than one home in a two-year period shall not be considered a Homeowner.
If you are applyingunder ''s section sign below: �-
Signature:
Your signature carries -certain responsibilities, -including but not necessarily limited 10, general liability
RESIDENTIAL
2(
a
NOTICE To LICENSEa CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
NP SECTION 4 WORKER'S COMPENSATION; SiiRANCE:AFFID
Workers Compensation Insurance affidavit must be completed and submitted with this application. Fa' ure to provide thhis affida
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: yes 0 no
_- ��,,_, _;,�����SECTIgN 5, DESCRIPTION OF PROPOSED WURi(check^all�ap hcablte� ��.�` ..��.°,
❑ new construction* ❑ addition ❑ alteration ❑ repairs 0 chimney/ ❑ wcoodstove
(energy report ' orf required) ` (energy report required) p q ) fireplace
❑ deck ❑ pool O accessory bldg. ❑ replacement window/door other ❑ demolition
(shed/garage) no.
of windows— doors_ specify below): (speciify 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)
❑1. None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
.._, 6 ESTIMATED CONSTRU�TI(5-C:OgTS . ,
' . �%
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildin
2. Electrical
3. Plumbing
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4) *Estimated Total $
3 .si '. '3 ....: i���..,..- :Vc�. a�a'.��y"*4.P rc-s•. e_.�,�, .3. .: p _. " #w n • x ,ate'=..-. .. - 'Y111®11��1
.::,t I..-.. '1M ._fi � 5 55 .,a„ } .. es,F,£r.r "aS S.'. *.$..,,,-r :'z•& .'G � °% ff$ ' i::}a %S" i> Wnm"yc', . y S i9. ': .ar w },
=. .: .. ftb'S'v�' �1 ,+. . 4 J. F-^. '�,.v;-t4P. a:
SE . .. _..
CTION 7A -OWNER ` wf., ;.�. ,
.; AUTIiURIZATION,
µ$me to ecom ,.«�,.. k
pleted,yvhenowner sFa entprcontractor,a he Win:-w
s,for bulldtn �.
e _.. ,g. ... ,u_
.:. w.,
(please print)
I,
as Owner of the subject property hereby authorize(,'.
to act my behalf, m all tter atiGe to work authorized by this building permit application.
!
Signature of Owner Date
g
,'$PA
r 4„..
„... .w : a.3 , "DIE
:
, as Owner/Authorized Agent hereby declare that the statements and inforrmation
-,�
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/Authorized Agent
natP
C:\bldg. forms\Bldgalsp.res.wpd
Page 2 Rev. Januard 19.2001 r•�t,i i� f .> �tui _ ..._a
Y
NUMBER OF PLANS SUBMITTED:
1.1 Property Address: n Lu
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
SITE PLAN SUBMITTED: yes ❑ o
„+ 1.2 Assessors Plat& Lot Number:
L1 Plat - Lot--
1.3 Historical District ❑ yes "no
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
i Municipal❑ Private Well Municipal ❑ On Site Disposal System,
C:',.bldg.farms\Bldgapp.res.wpd Pace I _ Rev. Januni 19- 2,M1