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BP-42407N 2005 RESIDENTIAL �r s OR N �.. Owner of Record: _ .1 11tigzV F Name (print) Contact Address Phone Number 2. 2 Authorized Agent: s Name (print) Contact Address Phone Number �A �Y•3 i S `ov9xja d:6` X&`''y�`"�`e.. .��`5` ,. L f "F �••�- k �� � �/ . 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)? 2-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 ' �,Aig �CiG�C'!�1 P.G/ j aif Registration Number (if none, state "none") � 3 Address g� Ltt�� Sgnatur — Telephone ��iC%�° Expiration Date %- 3.3 For esidential R ork 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) Signature nature by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund Date ..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 dwelline, 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 under this section sign below: Signature: Your signature carries certain responsibilities, including but not necessarily limited to, general liability C:\bldg,forms\Bldgapp.res.wpd Page 2 Rev. June 26, 2003 RESIDENTIAL 2005 .NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulati ons se ction tton that any It1censed Co nstruction stru ctio n Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) a ` � WORI{ER: S CQMPENSATIO lIR �' � � a � � � ,.SECTION �v Workers Compensation Insurance affidavit must be completed and submitted with this application. Failuire to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit lAttached:❑ yes ❑ no ..,. P, checkvl; ltcabl" z SECTION 5 �1ESC12tP .... P- : , rb .z..• ❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimneey/ ❑ woodstove (energy report required) (energy report required) fireplace; p accessory g ❑ deck oo n ❑ pool ❑ accesso bldg. . ❑replacement window/door ❑ other ❑ demo lition (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: rx) le L 62 I-7-a el mat SECTI ©leT'-6L STIMATiT1''C(3NS.)RCiCTiUNCQSTS ; �i"� v im`�� � •: ., W, .,¢`:: ..aa•,. ..v `•i'` `�'^' <° Estimated Cost ($) to _.., .... � ,e -..,�, x� �. _ , _ ,.,. «_ Item be completed by perrrriit applicant 1. Buildin 2. Electrical 3. Plumbing 4. Mechanical HVA 5. Total = (1 + 2 + 3 + 4) * Estimated Total $ 00, "& �; - ...., .,. ,... .�.. ..., .:.. ,�.., �' � , ,-�e�rrrYri�r%,�_._('►WN1wTl i1':t�TFdflRF7:A'f'1�71 .:.._ � _� ..<......�..�: ..v..«:=.: �=�:..r _; on tuc iviu�;vuiy, Signed u er the pains and enalties of perjury. j' ft "ture of Own %Autho ' Agent C:\bldg.forms\Bldgapp.res.wpd Page 3 RESIDENTIAL 2005 RESIDENTIAL— 2005 .. .... ..,ate � � � F�v � �.• s�CrtQ�;B mtsr.>�CTOR:s i�vr���/cQm��NT� �,� �� �... FOZINDATION ONLY ,�.,.9e.>_ r$25.00 APP�I,ICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE 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: Date: 8. Comments: 9. Inspector's Signature: Date: NOTIFICATIQN .. Applicant informed of above Date: , Time-.--:� Clerk: I Comments: G al ECTiCiI 20 QFFICE�INSl'ECTOR .,< . Total Permit Fee: $ <_�M 00 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 C SEC T[aN 1 �DITIQNAL ,,,COMMEN T SISKETCHES� q,.. I i CAbldg.forms\Bldgapp.res.wpd Page 4 Rev. June 26, 2003 ;/ I unicipal❑ Private Well ❑ Municipal �J76n Site Disposal System CAbldg.forms\Bldgapp.res.wpd Pagel Rev. June 26, 2003 1 r�! G