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`SECTION'4 =WORKER'S COMPEN$ATION.:INSURANCE°AFFIDAVIT (MGL'c 152 § 25) .
3.1 Licensed Construction Supervisor/Specialty License
Not Applicable ❑
- .
Licensed Construction Supervisor /Specialty License
License Number:
-
Expiration Date:
i
Address:
Signature: - Telephone:
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
®
e improvement Contractor subject to (780 CMRA 10.R6)? ❑Yes ❑ No
Are you a Homp
If No, go to the next section!
Are you claming exemption from the requirements? El Yes ❑ No
If Yes, submit the required affidavitl
Registration Number (if none, state "none"):
Company Name:
I
Address:
Telephone:
Expiration Date:
Signature: -
3-3 For Residential Remodel Work Only
P❑RaONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
Home Improvement Contractors
❑ I am a Homeowner performing all the work myself.
0v� ers Name (print):
l
Signature %`
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fun
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, noti di buildings
air, removal or demolition involving idual
.. alteration re
sha;21 engaged in directly supervising persons engaged it construction, reconstruction, p
rEEZ'
ctures, unless he or she is licensed in accordance with therulesand regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
visorsption: 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 persons) for hire to do such work, that such Homeowner shall act as supervisor.
Fbr 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 farnilydwelling, 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 beon csidered a Homeowner.
If you are applying under this section sign below:
Signature: ✓f
Your signature Carnes certain responsibilities, including but not necessarily limited to, general liability
i
Worker's Compensation Insurance Affidavit must be completed and submitted with
this a plicaAttion. Failure
❑Yes toAprovi ❑ Noe i
affidavit will result in the denial of the issuance of the building permit. Signed
Affi
SECTION.5
❑ Deck ❑Pool ::c2e
rs
❑ Alteration ❑ Chimney/Fireplace ❑, WoodstovelPellet Stove
❑ Roofing/Siding ❑ (Other
❑ New Construction" sory Bldg. ((Specify below)
(Energy report required) (Shed/Garage)
111iDemolition
❑ Addition ❑ Replacement window/door ((Specify below)
,r ..., .o.,,,f No. of windows Doors
if new construction, please complete the following:
Single Family: No. of Bedrooms
No. of Baths
Fwo Family:, No of Bedrooms Unit 1
No. of Baths Unit 1
No. of Baths Unit 2
No of Bedrooms Unit 2
9 Furnace (hot air) - fuel gas (natural or propane),
fuel oil, electricity, other (specify):
3 Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
7 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
7 Air conditioning : (separate unit)
I None of the above to be provided
Fuel Oil ® Other
B Hot Water Gas Electric ______
__--
;Please Print) hereb authorize
as Owner of the subject property y
o act on my behalf, in all matters to work authorized by this building permit application.
Date
of r)%Ainar
�� , as Owner/Authorized Agent hereby declare that the staterments and information
�pplicat are true and accurate, to the best of my knowledge and belief.
'pains and penalties of er u
P j ry•
Date
er d Agent
I
MENTS
RESIDENTIAL ❑ Approval i Part
SECTION 8:,- INSPEC.TOM REVIEWLCOM = .. y Per 780 CMR 5919 93)
INIIA11 1 A 12nno $25.00 APPLICATION FEE IS NON RE -FUNDABLE & NOY218 ABLE
,.,�,,., too...,.•+•
Signature:
Date V 19 200a
Date:
r .. .SECTION 7 '`SITE 1NFOR.MATtON _.
1.1 Property Addres `: <p 1.2 Assessors Map &Lot Nt imber.
A2
17
Frontage Map L) [Lot _
Lot Area (sf.) 9
Required Provided
Front Yard 1.3 Historical District l❑ Yes ❑ No
Side Yard Has application been submi{tled to the Historic Commission?
Rear Yard ❑ Yes ❑ No Date:
1.4 WatScupply (MGL c4 54): 1.5 Sewage Disposal Syster rivate Well ❑ Municipal ❑ r5 Site Disposal System
.
El
CONSTRUCTION PLANS SITE PLAN ENERGY REPORT