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END SECTION
75
VA
Residential
1999
2.2 Authorized Agent:
1
Contac ddress
Name
) �
/ Telephone)
�
:(print
:.»:. CO�-:'*.::::::::>
�......
..
: .
3.1LicensedConstr Construction Spervisor:
r✓ Alf 0J ' �
Not Applicable
Licensed Construction Su ervis ®� ff
F'
License Number O9 J
Address /
Expiration Date
/0/ - z1199
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
Signature Telephone
Expiration Date
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH C 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)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
4
3 ,' 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,
effectivc, 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
sect;on; 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 underthissection sign below:
r
Signature: V
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
Residential 1999
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any, licensed
Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Apypendix of 780
CMR R5.2.15)
Workers Compensation Insurance affidavit must be completed and submitted edwiapplication.with this Failure to prcVide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ nio
Z
new ❑ addition ❑ alteration ❑ repairs ❑ chimney/fireplace 10 woodstove
struction*
❑ deck ❑ pool ❑ acces ldg. ❑ replacement window/door ❑ other ❑ demolition
t she ra of windows doors
( g) _ _ (specify below): (specify below):
* If new construction, please complete the following: I
Single Family:v� no. of bedrooms no. of baths 3(/
Two Family: no. of bedrooms unit 1-no. of baths unit 1
no. of bedrooms unit 2 no. of baths unit 2
Brief Description of Proposed Work: CesA,4
.J
::>:::>:>::»:::>::>:::>:;::>::::>::::::>::<.>::::>:::>::»::::>:::.» wEIIMzSTEi�.#JIYTRUIf�N.C(OS.TS....; ......::::::>::::::>:::>::::>:::::>:::>:«c <`
Item I Estimated Cost ($) to be completed by permit applicamt
3f�A=W.
* Estimated Tota l;�o, a--Vos
(please print) —r / 1
as Owner of the subject property hereby authorize
to Et on my behalf, in all matter eI t, to work Auth�ized by this building permit application.
Sig ture of Owner Date
as Owner/Authorized Agent hereby declare that the statements rand information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
S'g erf d under he pains and penalties perjury.
Print Name r
Sig ature of Owner/Authorized Agent Date
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January 20, 1999
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Residential
1999
Residential
A
❑ FOUNDATION 0, , Y
1999
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. Inspector's Si
Applicant informed of above Date* Time: Clerk* I
Comments:
Total Permit Fee: $, sy,F, 00 I Less Application Fee: $ 25.00 ( Remaining Balance: $
TOTAL FEE: �!"��� �� Gross Area - New Construction total sq. ft. -r(9-7,e�-
Gross Area - Alteration total sq. ft.
I
Permit Issued To. � ���'� � '�; +�.,�•�' `S
7 1v r
� V
fig. 00
30. 0a
g0
0
c:\wpwin\forms\bldgapp.res Page 4 January 20, 1999
res
Page 1
10-,��3 �
January 20, 1999