BP-16658I4� I , 9c ICD
CL a3 C..;j CA t'ell it,
Residential
1999
22 Authorized Agent:
Contact Address
Name (print)
Telephone
...,
::_:._..................... .. .:."..:....:... ...._....:.:.:.::::."::::"_.................Q�1
..::::::.:.:::::
i�....
..
.:
3.1 Licensed Construction Supervisor:
Not Applicable El
Licensed Construction Supervisor
License Number
Address
Expiration Date
Si ature Telephon
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractorsubject to (780 CM 6). ❑ yes ❑ no
If n , go to the next section!
Are you claiming exemption from the requirement? ❑
If su it the required
affi tr
Company Name
Registration Number (if none, state "none")
Address
Sig-rature lephone
Expiration Date
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WIT G RED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY
FUND: QUESTIONS OR COMPLA cal or writer
Home Improvement Contractors istration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
OS3dners Name (pit) "
Signature
by s" ning the ove, the home owner acknowledges that there will be no eligibilty 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
139.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0,
of ctive 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, der this section sign below
Signature: a
our igna re carries c rtain responsibiliti„ s, including but not necessarily limited to, general liability
c:\wpwin\forms\bldgapp.res Page 2 January 20, 1999
Residential 1999
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that -zany licensed
Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. ` (see,/Appendix of-780
CMR R5.2.15) _
Workers 'Compe
nsation Insurance affid
avit must be completed and submitted with this aPP
llcarionaffidavit
ailure to�I ro_ vtde this
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Ayes -Q ; no
❑ new ❑ addition ❑ alteration ❑ repairs ❑' chimney/fireplace; ❑ woodstove
construction*
❑ deck pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑demollion
(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
Twn Family- nn of herlronme unit 1 - no. of baths unit 1
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5.Total =(1+2+3+4)
(please print)
1, , 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.
Signature of Owner Date
L-Si
y ma n _ t , as Owner/Authorized Agent hereby declare that the statemments and information
bregoing application are true and accurate, to the best of my knowledge and belief.
under the pains , n Ngiesperjury.
a k'�i
ireW Owner/Authorized Agent Date'
c:\wpwin\forms\bldgapp.res Page 3 January 20, 1999
Residential '
1999
::.::::.::::::::::.:.::........................................a:.:>€wlcQmct
:::...:................::..:::..........::.:::::.::::::::
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:
8.
Comments:
9.
{
Inspectors Signature: r
X. .
.......... ....., rrrn:....r: rcY� ntm,r�r�rrrr ertftv_. ..........
.. ....:..: �_ ':
Applicant informe4 of above ate '" Time: i!f Clerk•
Comments: a`/&/ 11<
(9,r/A�
Total Permit Fee: $ S Less Application Fee: $ 25.00 Remaining Balance: $
TOTAL, FEE: Gross Area -New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To w '
---C7-_ %.
Residential ❑ FOUNDATIC .4,tONLY `
1999
}�
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