BP-52227s
-
co
CO
OO NLr) Ln a)ooLor- "co
c0 co co cod
>o����������
OQw _ 17�
co
rn
Woo I
,.4 o co (0 't o
— rn `�+ W
ow o)oirno6a000 � � E-, q
W 00 0o ao co col00 ► .-.
NZ
H
w X q
Y
Ld
z
a
N ►� Q /
J Z U Fz C XO mTv���.i z (� T�� .� ; 1
Z to QWVO Z-ZZZ (n O z�
O -n 0 Z®zWWW w Ln cs d
'Lo CA
cJ '; Q Q—O—ODUUUUU €
2 O W W W W WZZZZZZ
0_ 0_ 0_ .0_ 0_ F- I- I -ton
N►nOOOOu7 •�•�'� �+:G ' d F
Nnd-tr)u0r-
LLI
W
6�o�� �`Q CO
(�
ZNrO�oo i�.
/45•82 cn¢¢¢¢a¢¢ C43 o kr
�h c ti
I
ti.
U
� ti � U L9
RESIDEFTiAi. NOTICE O LICENSED CONTRACTORS:
T ENSED CON R CTORS: The Building Code provides In the Rules and Regulations section that anv licensed Construct
w .: SECTION 2 ;=::PROPERTY OWNERSHjP/AUTHORIZED
AGENT
2.1 Owner Record:
�a Lt-
a s N A0 ` S s'� Syq 7
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Nance (print)
Contact Address Phone Number
y
ECTION 3.-,CONSTRUCTION,
SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor:"
License Number:
I 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 claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name:
Registration Number (if none, state "none"): .
Address:
Signature: Telephone:
Expiration Date:
3.3 For Residential Remodel Work Only
4 _
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
❑ 1 am a Homeowner
e performing all the work myself.
Owners Name (pint) tws�i L
a t
Signatur .
By signing the iiboVt;the homeowner acknowle-_4s 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
109.1:1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 1,16.0, 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
Superv,';sors-
Excepition: 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) s for hire to do such work that such Homeowner
P O a shall act supervisor.
F - - „ i
orth .,, purposes
p p s section only, a Homeowner' is defined as follows. Y Person(s) who owns a parcel of land on whichhe/she resides or intends to reside, on which
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 than
one home in a two-year period shall not be considered a Homeowner.
If you are argder this section sign belo
Signature.
our signature carries 'certain responsibilities, including but not necessarily limited to, general liability
v .
TIMATED C N C N
Item Estimated
`f t0„
mated Cost ($) to be completed by perrniit applicant
1. Building
2- Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4) c7r�
�,
".S ... e:-jai
,,, , SECTIO __.-O � O � .. .. , , ... ,,, , , ,. .. N.7A WNER:.AUTHORIZATI
,x.fo i7e,compiefed when owner s,agent.or contractor. applies for:buitdtng,permlt)
(Please Print)
I, as Owner of the subject property hereby authorize
to act on my behalf, in all matters7elativ authorized by this building permit application.
Signature of Owner Date
a
S TION 76 OWNEW , O EDAGENT DECLARATION AUTH RIZ
/nthe
as Owner/Authorized Agent hereby declare that the statemwnts and information
foregoing application are true and accurate, to the best of my knowledge and belief.
Signed der the pains and penaltiesof perjury.
ig ture o Owner/Authorized Agent Date
�,� KCt.tUltiCJ tIVJt'Cl, 1 UK 7"KCUICUV tSCt'UtSCF r"IC 1JJUHIVI.0 VI-�H t'CRlutt t � ,� -�
D PARTMENTAL.APPROVAL
Zoning Review:
Signature:
i
Date: v/� C)'"
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
!
Date;
'
Board of Health:
Signature: /
Date:
:7�2
Conservation Commission:
Signature:
Date:
Other:
Signature:
Date:
Brief description of work being performed:
G�
i
cll
1.1 Property Address: S-r,04 Z M A +r Z 1.2 Assessors Map & Lot Number: °
fiJ ALA .
Nearest Cross Street: Map ��-- Lot
I
Subdivision Name:
1.3 Historical District ❑ Ytes El No
Total Land Area Sq. Feet: Has application been submittecUlto the Historic Commission?
Yes ❑ No pate: I
1. ater Supply (MGL c4 54): 1.5 ewage Disposal S70n
I ❑Municipal E Private Well ❑ Municipal Site Disposal System
14,0,0 het s
�.S ❑ CONSTRUCTION PLANS ErSITEPLAN El ENEIRGY REPORT I