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BP-39122RESIDENTIAL 210 wner of Record. �aHN �-1 OWE owNefZ 53 M1uEIt,5' tre,9.DAAX"urn MA ©777 41 Name (print) Contact Address Phone Number 2.2 Authorized Agent: n! Z A V - �7JIS� i-�©1,.1� $1�uS�'/t�W vl S�f � &o Name (print) Contact Address Phone Number ry - M/ O C z 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor License Number - Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor: Not Applicable ❑ Fire 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 Registration Number (if none, state "none") Signature i Telephone Expiration Date p p 3.3 For Residential Remodel Work Only PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: UESTIOl��S OR COMPLAINTS callor write: - -Home Improvement Contractors Registration, One Ashburton Place -Room 1301, Bosun, MA 0210&, (617) 727-8598 Owners Name (print Signature b signing the above the home owner acknowledges that there will be no eligibilty to the Guaranty Fund 'Y b'm g � g Datej-2 or _.. 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 indirectly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements ofbuiidings 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 Supervisors. Exce tiotr, An Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner I p Y P g _ 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 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 ax two-year period shall not be considered a Homeowner. If you are applying under t s section sign below: Signature:-� Your signature carries certain responsibilities, including but not necessarily limited to, general liability Rev. January 2005 C:\bldg.forms\B.1dgapp.res.cvpd Page 2 RESIDENTIAL NOTICE To LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Constructicon Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) A ©N"'t < YAA NT Gl ,1 a 'CAA �� ,� �.�+" S ., Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide thus affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ZKyes ❑ n a M ;�a: '� -gA l lto VCx!llcaN Qa 1� vP` sEDRt {1leclk all applicable)`; r „'?� , i ' 'f,FS: , C,.0 . •�'...xuu ':: `•im' `DA'A" t r.ay". Wgl; ❑ new construction* ❑ addition alteration ❑ repairs ❑ chimney/ ❑ woNdstove (energy report required) (energy report required) fireplace ❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ dernuition (shed/garage) no. of windows_ doors_ (specify below): (specify"below): lease complete the following: * If new construction, p p g: 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 A'11 9 SCE FT o€ 1_i ING KE-A itS 6AS€A1E �� To Brief Description of Proposed Work: — c ItJC e.-V F— LAtoNbjL FULL_ SAT)-1goo$A A-W7 K1T AREAS. BAK SI G 1 ICE Vr7C Ile +w©NS7 , �a Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 1 5. Total = (1 + 2 + 3 + 4) *Estimated Total $ v i x, y R>s �-m 3 f y a; Y 0n 47 a cgmplefiesl vu'lien �r�ner�.s ,agei�k�or�can��cUi ap ''1te�"vr bt[tldin�, perms z-01 _(please print} as O r /edy s e property hereby authorize to act on my behaif, in all matters relative to work aut ri t ilding permit application. Signature of Owner Date yx5s-:- €..::, ,,ILL rE as Owner/Authorized Agent hereby declare that the statements and is iformation on the foregoing application are true and accurate, to the best of my knowledge and belief Signed under the pains and penalties of perjury. = 2--(o S Signa e of OVner/Autharized Agent Date C:\bldg.forms\Bldgapp.res.wpd Page 3 Rew. January 2005 RESIDENTIAL ❑ FOUNDATIONONLY PLICATION FEE IS NON -II iUNOABLE & NON -TRANSFERABLE C:\bidg.forms\Bldgapp.res.wpd Page 4 Rev. January 2005 C:\bldg.forms\Bidgapp.res.wi>d Page 1 Rev. January( 2005