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2.1 Owner of Record:�1�
l- 01n a,LJo ' q-- c v6v I Hili
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
;:.:.. .
XX
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 claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name
Registration Number (if none, state "none")
Address
Sienature Telephone
Expiration Date
3.3 Por Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUiESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617j 727-8598
Owners Name (print)
Signaturo
- by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4Homeowner 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
tha,^n 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 cenainpo, bilities, including but not necessarily limited to, general liability
RESIDENTIAL
n , Rev. January 20, 2000
c:\wpwin\forms\bldgapp.res Page 3
Rev. January_ 20,_2000 ____
RESIDENTIAL
2000
RESIDENTIAL 13 FOUNDATION ONLY 2000
$25.00 APPLICATION rEE IS NON®REFUNDABLE & NON TRANsrEIKABLE
1,
Date plan reviewed:
2,
30 days to review period expires`.
3,
OK to issue dater
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 Appealsaction:
Date:
8.
Comments:
9. Inspector's Signature: AP91A 2-0-90
Applicant info d ofdKove Date: Time: Clerk;
Comments:
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 Tom 1—:? r
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4
cAwpwin\forms\bldgapp.res r Page 4
is
Rev. January 20, 2000