BP-41408RESIDENTIAL
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2.1 Omer of Record:
/14 ame (print) Contact Address Phone Number
2.2 Authorized Agent;
Name (print) Contact Address
Phone Number
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor_ License Number
AddressExpiration Date
;,Signature
3.2 Registered Home Improvement Contractor: � U J �i�t`i$(�!Z �� Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes 9'
no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes lkno
If yes, submit the
required affidavit!
Address s Company Name
Addr��. Registration Number (if none, state "none")
ess 1 - 7 `J Od0
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 Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners. Name (print
Signatu_ e
by signing the above, 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
109.1.11 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 supervisingpersons 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 persou(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 i n a two-year period shall not be considered a Homeowner. -
Ifyou are applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
new construction* - ❑ addition ❑ alteration ❑ repairs
❑ chimney/ 011woodstove
(energy report required) (energy report required)
fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door
❑ other ❑' (demolition
(shed/garage) no. of windows doors
(specify below): (spfecify 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 - (separateunit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: (
ZS
Item Estimated Cost ($) to be completed by permit applicant
1. Buildin
2. Electrical
* Estimated Total l- $ 211P.000
EMU
as Owner/Authorized Agent hereby declare that the statements and iinformation
on the foregoing application are true and accurate, to the best of my knowledge and belief.
ZS11 ed under the pains and penalties of perjury.
Signature of Owne Authorize Agent Date
C:\bldg.fonn§\Bldgapp.res.wpd
Page 2
Rev. January 2005
C:\bldg.forms\Bldgapp.res.wpd Page 3 rev. January 2005