BP-39758RESIDENTIAL
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2.1 Owner of Record.
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Contact Address Phone Number
Name (print)
2.2 Authorized Agent:
Name (pant) Contact Address Phone Number
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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)? ❑ 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
4 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:
Home Improvement Contractors Regist-ration, One Ashburton Place - Room 1301, Boston, AM 02108, (617) 727-8598
wners Name (print))�c
Signature JPaAS=a—� A-Ag"=Q
that there will be no eli ibil
by si ng the above, the home owner acknowledgesbn tY 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,E Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
shall be erkgaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements ofbuildings
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 tEe 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, oir 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 yap ng un r this sectio . below:
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Signatur ..
Your signature rries certain responsibilities, including but not necessarily limited to, general liability
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RESIDENTIAL
n licensed C onstrue
section that a Lrion
x :The Building Code provides in the Rules and Regulations y
F
CE TO LICENSED CONTRALTO Sg rvisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide tthis
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑
n
0
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ wzoodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool El accessory bldg. ❑ replacement window/door El other
4e�molition
(shed/garage) no. of windows doors_ (specify below): (specify 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:
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Item Estimated Cost ($) to be completed by permit applicant
1. Buildin
5. Total (1 + 2 + 3 + 4) *Estimated Total $
�%' F
\ to be i otn etcd a wtter : a etl rho traiito�alspie ia� 171�(11, �i 1
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3.
(ple se print)
I, �VaJ L4- � I , as Owner of the subject property hereby authorize
to in behalf in all matters relative to work authorized by this building permit application.
_moo cl • l�-,�
denature of Owner/7 Date
I as Owner/Authorized Agent hereby declare that the statements aned information
on the foregoine application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
0— P.
Signature of Owner/Ai
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Agent
Page 3
Date
'Rev. January 2005
Inspector's Signature: Date: td�
O r
la�rr � �J
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Applicant informed of above bate: Time: Clerk:
Comments:
Total Permit Fee:
Less Application Fee: $ 25.00
Remaining Balance: $
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TOTAL FEEr��O 0 ®
Gross Area - New Construction total sq. ft.
-
Gross Area - Alteration total sq. ft.
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Permit IssuedTo- 11V rf i2 i Q
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Page 4
Rev. January 2005
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
Assessors Map & L t dtnber-
1.1 Property Address: / 6 /�
Map Lot -
Nearest Cross Street:
Subdivision Name: 1.3 Historical District ❑ yes ❑ no
Total Land Area Sq. Ft.: Has application been submitted to the Historic Comrmission?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal Syst m:
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