BP-59437RESIDENTIAL
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:1 Owner Record:
Tim GZa I ,ZA Z,d
Name (print) Contact Address Phone Number
,iQl�7"IYy v>' 4�7G
2.2 Authorized Agent:
Name (print) Contact Addr s ems Phone- Number u ber
..: SC[i3Nf;"..,C: C3T C)1�4 SI~RtC 55
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3.1 Licensed Construction Supervisor/Specialty License: 4e v ?"f�r CT1� License Number: C
ompany Name/Contractor Name: &WSMUGr)01) e0,
C Addressr (3q f2, ,� SQ-" 2� �5 Expiration Date:
O Signature: Telephone: TDi--s7l-p/s2,
P 3.2 Registered Home Improvement Contractor: ID, Not Applicable ❑
Y �
0 Are you a Home Improvement -Contractor subject to (780 CMR.110.R6) ± Yes ❑ No
F Are you claming exemption from the requirements? ❑ Yes 0 No
L _ If Yes, Go to Section 3.3
Company Name/Contractor Name:
Ld "`' / Registration Number (if none, state "none
C , Address,
E `4 Signature: , Telephone: 0 7fp/ �j'�-.. Expiration bate: 9 /7//25
N 3.3 For Residential RemQfiel Work Only
C PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
E QUESTIONS OR COMPLAINTS call or write:
(S) 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:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 Licerpsing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building.
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 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:
Signatur&.
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
Page 2 Page 3
.r� Less Application Fee: $25.00 Remaining Balance: $ �-42
Total Permit Fee: $ � 41
Other $ Amount $
TOTAL FEE: 7 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to
Page 1 `1 .