BP-44001ESIDENTIAL ;.
GENT ED A
'RTY OWNERSHIPIAU THORIZ .
SECTION 2 PRQQE ,
S6q S�5011P5
2.1 Owner Record:
39 Luc, U,AQU
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Name: (print) Contact Address Phone Number.
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
-; SECTION 3 - CONSTRUE
T10N SERVICES
3.1 Ltcensed Construction Supervisor. Not Applicable ❑
j License Number:
Licensed Construction Supervisor:
Address: Expiration Date:
W Signature: Telephone:
Registered Ho Re I
Home Z 3.2 Improvement Contractor: Not Applicable ❑
9
W
V Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ Yes ❑ No
J If No, go to the next section!
LL. Are you claming exemption from the requirements? ❑ Yes ❑ No
o If Yes, submit the required affidavit!
Company Name: Registration Number (if none, state "none"):
a
® Address:
VTelephone: Expiration Date:
Signature:
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):
Signature` By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date..
e
3.4 IHomee'wner Exemption - One & Two Family Only
L
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
shalt 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.
provisions of this section provides that if a Homeowner
work for a Building Permit is required shall be exempt from the p , p
Exception: Any Homeowner performing 9
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. v
If you are applying under this section sign below:
Signature: Z,
Your signa a carries certain responsibilities, including but not necessarily limited to, general liability
i
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any lii ensed Construction
P
Su ervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR- R5 2 15)
-- FFIDAVIT IlAGL c 752 25� ::.
.SECTION 4 -..WORKERS COMPENSATION INSURANCE A ( § ?
Worker's 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 01'No
'le
{ ��: , , .. , , •SECTION 5 -:DESCRIPTION OF PROPOSED WORK (Check alLapplccab,
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodsteive/Pellet Stove
❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specifyrlbelow)
❑ Addition ❑ Replacement window/door ❑ Demolitiion
(Energy report required) No. of windows _, Doors _ (Specify,tbelow)
"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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed work: - ocat 1 � V
E T::
w CTION 6 - ESTIMATED,CONSTRUCTION COS
S
Item Estimated Cost ($) to be completed by permit apfalicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC) -
5. Total +2+3+4)
f
,.
WNER AU RIZATIO 'N
r
THO
SECTION 7A=- O� .
.,:. , ctora ..lies for butldm ermit
� . =(to be completed.when owner's agent or contra pp , 9 p ) ..
lea a Print)
I, %VV ix as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
q-6(-AL
S 6nature of Own r Date
SECTION 713 ;OWNER/AUTHORIZED AGENT„DECLARATION
('� 1
as Owner/Authorized Agent hereby declare that the statements ;and 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.
C)
Signature of Owner/ �thorized 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:
Comm,ents:
_ Less Application Fee: $25.00 Remaining Balance: $� "^
Total Permit Fee: $
Other $ Amount $
TOTAL FEE: ! S Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to le
` y r
CONSTRUCTION PLAN
'E PLAN ENERGYREPORT