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BP-12160t1 og� ;o � ?`rn m Ir 6CDimpPV 1 v ca rm Pat i Residential 1999 Residential 2.1 Owner of Record: IhICHRCL f Z RN IS Name (print) A A QC'>y LS Name (print) 3,1 Licensed Construction Supervisor: LicensedECo;njs7truEc;tion Supervisor Address p©(X-S Signature Telephone 3.2 Registered Home Improvement Contractor: (2�o1�� `� ►� Contact Address ai-l+kr 17RX Phone Number S�? �S-7?bi C- 2r7. �9�-332-o Contact Address Phone Number Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no Are you claiming exemption from the requirement? If ❑ yeS O no oe next section! If yes, submit the required affidavit! Company Name p A t S � 5Q0S Address 7 56>'-1 f-e- — Telephone -996 - 3 3 20 3.3 For Residential Remodel Work Only Not Applicable ❑ License Number Expiration D # &/00 Not Applicable ❑ Registration Number (if none, state "none") /6g'oR C� Expiration Date Q- Oc 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 Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund 13.4 Homeowner Exemption - One & Two Family Only TO PERFORM AND BE LE FOR THEIR O 109.1.1 Licensing of ConstructionFOR HOMEONERS WHO Supervisors: Except for those ostructur s governed by Consstrucation Control inSectionoJECT 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 p�-rposes 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 apptvinQ tUerifiis,section giQn hPk,..,• A Your signature —al uunioWues, including but not necessarily limited to, general liability 1999 NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Cconstruction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of ::::::.:::.:.: .. PP 780 CMR R5.2�.1 .............. S�C'fT(J1�.�.»:VF!�pu:it:rrt� Workers Compensation Insurance affidavit must be completed and submitted with this will result in the dental of the issuance of the building permit. Signed Affidavit Attached: shed: Failure yeS 0 roj ode this affidavit ❑ new ❑ addition ❑ alteration ❑ repairs construction* ❑ deck O pool ❑ accessory bldg. ❑ replacement window/door (shed/garage) no. of windows_ doors_ * 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):_ o HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify): o Air conditioning - (separate unit) None of the above to be provided Hot Water: Gas Electric ❑ chimney/fireplace ❑ other (specify below): -- Fuel Oil— Other Brief Description of Proposed Work: C' - ----- Item Estimated Cost (S) to be completed b P y permit applicant.. ob 0 "? 0 0 5. Total = (1 + 2 + 3 + 4) (please print) * Estimated Total $ 16 —/QC) ,I'- 6 M CkPrE,I' JT I --pc( r E 1' 1, as Owner of the subject property hereby authorize to act on myV�l i 11 er lative o work authorized by this building permit application. Signature of Owner Date ❑ woodstove ❑ demolition (specify below): I , as Owner/Authorized Agent hereby declare that the statements and ii on the foregoing application are true and accurate, to the best of my knowledge and belief. nformation l Signed under of lKrjury. '3ignature ofOwner/. Agent Date 9. Inspector's Signature: i> Applicant informWill Comments: AUG 16 Mir Time:3/ 0 M Total Permit Fee: $ 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 s <,—,,+ �--r ft L Residential o FOUNDATION ONL ' $25.00 APPLICATION FEE IS NON-REFUNDABLE 1999 cAwpwin\forms\bldgapp.res Page 4 Rev. July 7, 1999 S17-e c:hvpwin\forms\bldgapp.res Page 1 Rev. July 7, 1999