BP-VOIDResidential
1999
2.2 Authorized Agent:
Co act Address '
Name (print)
Telephone
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3.1 Licensed Construction Supervisor
Not Applicable ❑
Construction `
Licensed Cons supervisor
License Number
e
Address +—
Expiration Date
Signature Telephone
3.2 RVfsteredflorrig0r6provefnent 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 claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the required
affidavit!
Company Name
Registration,Number (if none, state "none")
Address
Signature Telephone
Expiration Date
3.3 For Residenttzl Remodel Work Only
WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO T
PERSONS CONTRACTING CONTRAC O S HE GUARANTY
FUND: QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, tine Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name (print)
Signature , 4
by signing the above, the homeowner acknowledges that there will be no eligibilty 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 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 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.
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 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 a two-year period shall not be considered
a Homeowner.
If you are applying under this section sign below. -
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
Residential 1999
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed
Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 7780
CMR R5.2.15)..,
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Failure to pro
vide this a::
must be comp
leted and submitted with this application. .fidavit
Workers Com Compensation Insurance affidavit
PpP
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
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s Cr SC tN 4...
f ❑ new ❑ addition ❑ alteration ❑ repairs ❑ chimney/fireplace ❑ woodsttove
construction*
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door /6 other ❑ demolitfion
(shed/garage) no. of windows doors (specify below): (specify blow):
* 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 1
no. of bedrooms unit 2 no. of baths unit 2
Brief Description of Proposed Work:
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Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
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Residential
1999 _ Residential
FOUNDATION ON Y
1999
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. HOLD reason: Date'
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
9. Inspector's Signature:—,2 Date:
Applicant informed of above Date Time: Clerk -
Comments:
Total Permit Fee: $ D . (00 Less Application Fee: $ 25.00 Remaining Balance: $
TOTAL, FEE: Gross Area New Construction total sq. ft. _
Gross Area Alteration total sq. ft.
Permit Issued To
v
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