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1.
1
RESIllENTIAL 2001 RESIDENTIAL
SECTION 2 - PROPERTY OWNERSHIP AUTHORIZED AGENT
2.1 O«rrier of Record: `I ,t ��� 'ii't �� VA (Da �� �j j�
_ QQ
U
` 16_4-t�
\4N,qy\f_ L-e-_ ccv_�A_
ba_YAI� At�t� a2_7 7
Name (prin) Contact Address Phone Number
2.2 Authorized Agent: ��6 4,;h42 U f7 L/zl22
� 4,) > ,� C �� r�L s,! � fps �c��
/-u
Name (print) Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: bol LL -171 H f" JU 4j l� (91 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)? Xyes ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes X\no
If yes, submit the
required affidavit!
Company Name �'�' f �tt�/(p f�% �� S ,S aU C� Registration Number (if none, state "none")
Address 1,1A24LP1 LA4, D A5CG�}�
Signature Telephone Expiration Date 3 R o a,3
3.3 For Residential Remodel WVrk dInly
PERSON"S 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
y signin above, e hpm own acknowledges that there will be no eligibilty to the Guaranty Fund
Date
3.4 Hom owner 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 o- 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 hie/she resides or intends to reside, on
which there is, or is intended to be, a one or two familv 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 applyin n er this section sign belo
Sicnature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
u
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Cornstruction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.115)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pro%ride this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ n fo
_ check all applicable)
SECTION 5 DESCRIPTION OF PROPOSED WORK ( pp
❑ new construction* Vddition ❑ alteration ❑ repairs ❑ chimney/ 10 woodstove
(energy report required) ,fekergy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. . ❑ replacement window/door ❑ other [❑ demolition
(shed/garage) no. of windows doors (specify below): ((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 I
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:
daa"UG �1 �J , �
os� /
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicanit
1. Buildin
2. Electrical
3. Plumbin
4. Mechanical HVAC
C J_
r
5. Total = (1 + 2 + 3 + 4) * Estimated Total $ ,; _ o 0
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please pri )
Si t t ell
as Owner of the subject property authorize
to act � my behalf, in=tteslative to work authorized by this building permit applica ' n.
ail..
Signature of Owner Date
SECTION 7B - OWNE AUTHORIZED AGENT DECLARATION
-1 , as Owner/Authorized Agent hereby declare that the statements amd information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains aApenties of perjury. _
/2
_5 Qv� 'D )
-
Signature of Owner/Authorized Agent DatFP
C:\bldo. forms\Bldgapp.res.\%-pd
Page 2
Rev. January 19, 2001
C:\bld�(. forms\Bldgapp.res.wpd
Page 3
f1,ev. January 19, 2001
ZLUU1
-SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. ; 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals(see project review worksheet): Date:
5. DENIED (see project review worksheet): Date:
6. reason:4�DaAVN 14 2001
7. HOLD subject to ZoningBoard a Is action:
pp Date:
8. Comments:
•+.
v -
9. Inspector's Signature: Date:
SECTION 9 - APPLICAN. T NOTIFICATION
Applicant informed of above Date: Time: Clerk:
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $ JLess Application Fee: $ 25.00 Remaining Balance: $ Ge
47 C .1 7, -0
TOTAL FEE: j �•—�., Gross Area - New Construction total sq. ft. �
Gross Area - Alteration total sq. ft.
Permit Issued To-- ��-''� X
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
loo
r
RESIDENTIAL
11 FOUNDA TION ONL Y
$25.00 APPLICATION FEE IS NON=REFUNDABLE &'N..ONwT.RTWNSFEItA13LE
Energy Report:
Signature: 0
CAbldg.forms\Bldgapp.res.wpd Page 4 Rev. January 19. 2001
W ,ram C)
l.J
Rev. January 19, 2001