BP-44305RESIDENTIAL
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record: ,Q
.sue
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
SECTION -:CONSTRUCTION SERVICES
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 claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name: Registration Number (if none, state "none"):
Address:
Signature: Telephone: I Expiration Date:
3.3 Cor 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.
Ovrners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility 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
109.1.1 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 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 appl kg
under th ection sign below:
Signature:
Y ur ignatur carries certain responsibilities, including but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that anyj licensed Construction
Suoervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 C��R R5 2.15)
SECTION 4'= WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 15Z %z5)
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to providfe this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes f❑ No
SECTION 5 ='DESCRIPTION OF' D WORK (Check all applicable) .
❑ Deck ❑ Pool ❑ Repairs Iteration ❑ Chimney/Fireplace ❑ Woodtstove/Pellet Stove
❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other -
(Energy report required) (Shed/Garage) (Speciify below)
❑ Addition ❑ Replacement window/door ❑ Demoilition
(Energy report required) No. of windows _ Doors (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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description f proposed ork: 42
SECTION 6 -`ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit aipplicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
SECTION 7A = OWNER AUTHORIZATION ,
to be corn leted vvher ovvner's a ent or contractor a lies for buildin ermitI "
( P 9 PP 9P );
(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
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION .
I
as Owner/Authorized Agent hereby declare that the statemerift and information
on the foregVoi g application are true and accurate, to the best of my knowledge and belief.
Signed under the pain nd nalties perjury.
lv,
/Signature
of Owner/Aut rized AcentU Date
.SECTION 8- INSPECTOR'S 'REVIEW/COMMENTS
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:
Comments:
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON-TIIIANSFEBABLE
SECTI -`SIT FORMATION
1.1 Property Address: �7
Nearest Cross Street:
1.2 Assessors Map & Lot Number:
Map Lot/0 -�
Subdivision Name:
1.3 Historical District ❑ Yes ❑l'No
Total Land Area Sq. Feet:
Has application been submitted to the HistoTHc Commission?
❑ Yes ❑ No Date:
1.4 Water Supply (MGs :
L cA0
1.5 Sewage Disposal S=��posal,2�1System
❑ Municipal ivate Well
❑ Municipal
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT