BP-57997RESIDENTIAL
Not Applicable ❑
3.1 Licensed Construction Supervisor:
(� License Number:
Licensed Construction Supervisor.
�I
Expiration Date:
Address:
Signature: Telephone:
Not Applicable ❑
3.2 Registered Home Improvement Contractor:
® Are you a'Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No
II 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"):
i
Address:
Signature: Telephone:' Expiration Date:
II 3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS COMP i I*S call or write:
me Improv dent Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
II ❑ I am a Ho wrier performing all the work myself.
Owners Name.{ n
ignature: ,'
' I U - By s' ning the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
IW ,
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 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual
'n direct) supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
shall be engaged i Y P and Regulations for Licensing Construction
or structures., unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules a g
Supervisors-
Exception, Any Home rier rforming 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) f hi to o such work, that such Homeowner shall act as supervisor.,
For the purposes of; his se& on 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
one or two structures. A person who constructs more than
there is, or is intende� tq'be� family attached or detached structures accessory to such use and/or farm � Y dwelling,
one home ira a two -yea pe(i'rid shall not be considered a Homeowner.
1 # fjl
If you are aplyin rider section sign below:
i
Signatur -.
/ responsibilities, including but not necessarily limited to, general liability
Your signature carries certain
I
SECTION 4'= WORKER'S COMPENSATION INSURANCE -AFFIDAVIT (MGL
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ Nfo
❑Pool ❑Repairs El Alteration ❑Chimney/Fireplace ❑ Woodstovre/Pellet Stove
❑ Deck
0 Roofing/Siding ❑ Other
❑ New Construction* ❑Accessory Bldg. (Specify below)
(Energy report required) (Shed/Garage)
❑ Demolitiom
❑ Addition El Replacement window/door (Specify blow)
(Energy report required) No. of windows _____ Doors _ _
*If new construction, please complete the folloxwing:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1`No.
No of Bedrooms Unit 2 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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided Fuel Oil Other --
❑ Hot Water. Gas_ Electric
D mcripti®n of proposed work: I
777777777
(Pleasp/Prin(
I as Owner of the subject property hereby author- e
to a�f I ehal d1 matters relative to work authorized by this building permit a n•
;ate
ignq, u'ry�o ner
, as Owner/Authorized Agent hereby declare that the statements and information
I,
on the fore oing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Date
Signature of Owner/Authorized Agent
SECTION 8 - INSPECTOR'S REVIEWXOMMENTS
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD ?
Reason: �1✓3 Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: _
Applicant informed of at
Comments:
"�o Date: 9, —_ -' 'lj 5
Date
11g�1/1//, - �•
V Cl4/ -)2
SECTION V. - ADDITIONAL: COMMENTSISKETCHES
1.1 Property Address: , �re1� P� /,;)Y 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map :7 d Lot _
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard Has application been submitted to the [Historic Commission?
Rear Yard ❑ Yes ❑ No Date:
1.4 Water Supply (MGL c4 54): 1.5 Sewage Disposal System:
Municipal rEf Private Well ❑ Municipal On Site Dispoosal System
EICONSTRUCTION