BP-60959x, r
HOR1Z�
,,....
.1 Owner Record:
Iftr✓cfie r9 Z' s ,e woo
°i 23 'LOU �AIl I)yen, &,0,13
Name not
ti
Contact Address Phone Number
!2..Q2uqthhrizedt: �IM-7 U�l li � iwGtNnt)
=Contact Address Phone Number -
•, : ...,. ..,: ,,. ,. ,.,. yam,.- ../, �,� ..
��' . ... ,__,. ��.�..,, /, STRtJGTJoiV._SI=R - _ ,.,- .,, ,�.a'r.,,�,`✓� ,.,, 5 ,. ,.,
, F �� . �� ��; � �-� �-. ,:., . SEGTiON, 3;,�G�N , .
idi%ln, �i' �+.F .. a
� 2 ....>L`,� �.., ,
3.1 Licensed Construction Supervisor/Specialty License : License Number:
Company Name/Contractor Name:
Address:
Expiration Date:
Signature: Telephone:
3.2 Registered Home Improvement Contractor: '
Not Applicable ❑
Are you'a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes []No
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, Go to Section 3.3
Company Name/Contractor Name:
Registration Number (if none, state "none"):
Address:
Signature: Telephone:
Expiration bate:
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
am a Homeowner performing all the work myself.
ers Name (print): 4fA&CAe
k.O
Signature:
o the Guaranty By signing the above, the homeowner acknowledges that there will be no eligibility t Fund_
Date: 1�� U
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
6108.3.5 Licensing of Construction Supervisors: Exceptfor those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
demolition involving the structural elements of building
ed in construction reconstruction alteration, repair, removal or demo) n g 9
shall be engaged in directly supervising persons engaged P
or structures, unless he or she is licensed inaccordance with the rules and regulations promulgated by the BBRS entitledRulesand Regulations for Licensing Constructioi
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 Homeowne
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 whit
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 tha
one home in a two-year period shall not be considered a Homeowner
If you are applying under this section sign below:
_
Wi n J'
Signature: L , dt
.
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
c Vi � L. c 15
€ i=F1D T Ii+1G �,
Oil iNSURAtNG A
R�ER S-Q�t�f�PEI`dSA,t I , . ,-.,, . ,.-.. a,.A.., - ,�(
Failure to r_
his application. Worker's Compensation Insurance Affidavit must be completed and submitted with t pp p , ovlde this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
: y� SGTION Su`DESGRiPTIOt OF-'PROPOSi) �lilOftK` Checlail;appltcal�Ce)7-
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ %Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (
Shed/Gara e)
(specify below)
❑ Addition ❑ Replacement window/door ❑ [Demolition
(Energy report required) No. of windows Doors (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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed work:
_ r
w CQST .� C i1fS RilGTtQN .�.
Item Estimated Cost ($) to be completed by permiit applicant
1. Building
2. Electrical
3., Plumbing
4. Mechanical (HVAC) g -�
5. Total 0 +2+3+4)
y
et r r
� s
�� 17ATiC?I� � a: �� ER AUTI�O .
ON 7`A�
� � SECT-4
�t � .� � ��x ,. �> �� � �,,., . '_�.. �:'� , v�..
%11,��2 , �
m I ett;.ouuiner;s
(ta,I3e.cca- p eted,wh
(PI
`-I % jfJiV e �i /� . S�eYi /�>�aa� as Owner of the subject property hereby authorizi&---,Lly J � X e e- r� YR ,
to act on my behalf, in all matters relative to work authorized by this building permit application. --;=
Signature of Owners Date
',.
\.:. a.
. F G IRA�=rI - .. ... ....�, ,..,
� ,.,
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate,.to the best of my knowledge and belief..
Sinne der the pains and penalties of perjury.
Sign furOwner/Authorized Agent Date
- Page 2
RESIDUUM ❑ Approval in Part (Per 780 CMR.5111.13)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE NON-TMANSTIR+ E1,
DATE RECEIIV7 b
1. Date plan reviewed: SEP 10 2010
2. DENIED (see project review worksheet):
Date:
3. HOLD _�%�i�'1/�
Reason: Date:
4� HOLD subject to Zoning Board of Appeals action. Date:
Comments:
Inspector's Signature:bate: EP 1
j^ Less Application Fee: $25.00 Remaining Balance: $
Tbtal Permit Fee: $
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area Alteration total sq. ft.
�
--, 1J
a `
Permit Issued to: r 1 IL