BP-29260RESIDENTIAL
tl*tly �x'NERSHIP; / AUTH4I
!l ?I, _f�I.,,1114
Contact Address
2.2 Authorized Agent:
Addres
Signature Telephone
3.2 Registered Home Improvement Contractor:
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
r
Address
Mi Jgnature Telephone
3.3 Fo. Residential Remodel Work Only
SENT
Phone Number
Expiration Date
Not Applicable ❑
Registration Number (if none, state ❑ none❑)
Expiration Date
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
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4 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
buildinzs 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
Constn�ction 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 Vnere 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 conside a Homeowner.
If you z_re applyi b under i ectio sign to
Signatthre:
Your signature/
ies certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construcstion
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
* 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: �� j d �� �O'D"o, Ile- ac", t;�Lc o e �e r-o c k, rao nA r :� / L', I -C �,
.x, D N TRUCTION COSTS
.. u
_.
�� :SECTIf)N - ESTIMATE Ct7 S
...
a..
_
Item Estimated Cost ($) to be completed by permit applicant
Signature of Owner/authorized Agent
6" 03
Date;
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RESIDENTIAL 2002
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE S5 NON-REFUNDABLE & RTOiGTHiAT!!SrERABLE
9. Inspector's Signature:
Date: &Z //
CTIC N AOT P
LICANT NIFICATION
; .
..._.. f
_ , ..
Applicant inf9rr9ed of above
ate: UUU Time:'
Clerk:
Comments:
x w
SECTION 0- OFFICEVNSPECTOR -S NOTES0
Total Permit Fee: $ a
C%
Less Application Fee: $ 25.00
Remaining Balance:
$
TOTAL FEE: ,��t5;e1690 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft. frd
Permit Issued To: $wll <� 1�' l�J7C�c.c- c�'1 e��`P� E :��
�: -
,SEC ON 1 � _��ADDI'>I"�t�N�L COMMENTS/SKETCHES
F
.:-#»
RESIDENTIAL
❑ FOUNDATIOAT V'
$25.00 APPLICATION FEE IS NONwRE1119NOABLE &----NOWwTt9AN'-;'FERARL.E
2003
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Rev. January 1, 2003