BP-55501SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
1 Owner Re. -
w
ame (print)
Contact Address Phone Number
2-2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3"-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor.
Not Applicable ❑
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Licensed Construction Supervisor: t?G\Ae-c� co,1O(C \
License Number. C5 —�>L. Rat &147
Address: 12 mac' c �ac iYtcs.�11 (tit1' ®Z `17J
Expiration Date:
Sig natur Telephone: bZ3s- 7TS-5 b-7i
3-2 Registered Home Improvement Contractor.
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
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Company Name: Nh AWE C1 QCL C"\ ryMY\A,Z,Ac-
Registration Number (if none, state "none"):
i o� �
Address: 'lf� � �c e �� is aw'� wte��s Mn M6 0 a.Z H"j
�Slgnature: ' Telephone: �S�t `Z`t3-55-77
Expiration Date: 3
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
I am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date:
3A 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: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
sh6ll 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 sheds licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
Su-jervisors.
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.
Fbr 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
theTe 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 under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
SECTION 4 -WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25)
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure tCJ provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑,'Yes ❑ No
7777777777777
SECTION 5 - DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration 0 Chimney/Fireplace El Woodstove/Pellet Stove
❑ New Construction" 0 Accessory Bldg. ❑Roofing/Siding 0 Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door [p 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 Fu Oil Other
Description of proposed work: Lf 00
SECTION 6 -;ESTIMATED CONSTRUCTION COST
E f t d Cost ($) to be rmmnleted by ciermit aoolicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4)
SECTION
pleted when owne
(P Print) 1 ( n t
1 itwc� �c r ��vuyvlNe
as Owner of the subject property hereby authorize llsL
I, ®VI
to act on m eh If, in al ma s rela ive to work authorized by this building permit application,
l�-/16
Signat e of Owner Date
ON 7B - OWNER7AUTHORIZEDRGENT DECLARATION
SECTI
..: I 5 as Owner/Authorized Agent hereby declare that the statements and information
on t 9
he fore of 9 application are true nd accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
' Date
nature of Owner/Authorized Agent
SECTION 8 -'INSPECTOR'S REVIEWICOMMENTS
1. Date plan reviewed: ) 2 - es,
2. DENIED (see project review worksheet):
Date:
3. HOLD 7
Reason: /'` yr Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: � �f��. Date:
Applicant informed of above: Dat�, E Time: Cl r
Comments:
,r
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $S
Other $ Amount $
TOTAL FEE: 5 Gross Area - New Construction total sq. ft.
Gross Area -Alteration total sq. ft.
Permit Issued to . �� ch
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❑ Approval in Part (Per 780 CMR.5111.13)
IN FEE IS NON 14E-FUYI10ABLE & NON-TSANSFERABLE
SECTION 1 SITE INFFtO"RMATION
1.1 Property Address: uOoecc� —oc�1� fi�ctMe�` 1►, 1.2 Assessors Map & Loit Number:
Lot Area (sf.) Frontage Map � Lot fa
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard Has application been submitted to the Historic Commission?
Rear Yard Yes ❑ Nco Date: {
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
0 Municipal ❑ Private Well ❑ Municipal C73 On Site Disposal System
0 CONSTRUCTION PLANS SITE PLAN ENERGY REPORT