BP-39530SIDENTIAL 5 ,
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2.1 Owner of Record_ ue
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
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 ❑
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 Residential Remodel Work Only
} 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, AM 02108, (617) 727-8598
w Hers Name rint
0
Signatur
_-- �
y signing the ove, the home owner 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
mall be engaged in directly supervisingpersons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements ofbuildings
ar 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
t ?ere 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
cme home in a two-year period shall not be considered a Homeowner.
If you are applying un s section si
Signature.
Your signatu a rries certain responsibilities, including but not necessarily limited to; general liability
Page 2 Rev. January 2005
C-%ldg.forms\Bldgapp.res.wpd
RESIDENTIAL
NOTICE TO LICENSED CONTR
ACTORS: 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 780 CMR RS 2i:15)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to prfovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached.,: ❑ yes ❑
n
0
❑ new construction* ❑ addition ❑ alteration ❑ repairs
❑ chimney/ ❑ woodstove
(energy report required) (energy report required)
fireplace
❑ deck ❑ pool ssory bldg. ❑ replacement window/door
❑ other ❑ demolition
(shed/ rage) no. of windows_ doors_
(specify below): (specify below):
* If new construction, please ete 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
❑ 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 -
Electric Fuel Oil Other
❑ Hot Water: Gas
Proposed Work: ` t ( ----
Brief Description of 0 Cs
Item
5.Total =(1+2+3+4)
Estimated Cost ($) to be completed by permit applicant
* Estimated Total $� y
(please print)
I K'athnorized
er of the subject property hereby authorize
to act on my behalf, in all matters relati4�r by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent hereby declare that the statements and information
on the orego�nplicaon are true and accurate, to the best of my knowledge and belief.
Signed under the penalties of perjury.
Signature of Qwner'%
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Page 3
Rev. January 2005
Comments:
I
i
Inspector's Signature: Dater/
Ml
Applicant informed of above Date: Time: Clerk:
i Comments:
ew
TOR"rn
�s
Total Permit Fee: $ G Less Application Fee: $ 25.00 Remaining Balance: $.% . 00
TOTAL FEE: Gross Area - New Construction total sq. ft. j`` ; SO r- 7-
Gross Area - Alteration total sq. ft.
Permit Issued To- X f 6 S i.td
�)ITii�tI.A 1YN i �IE�iES
m / a ��//�
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Asse sors Map & Lot Number:
1.1 Property Address:�h r r� yr� Map_ ?o Lot _
Nearest Cross Street:
Subdivision Name: 1.3 Historical District ❑ yes ❑j no
Total Land Area Sq..Ft.: Has application been submitted tc�`the Historic Commission?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
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