BP-635992.1 Owner Record:
127f 7
Name (print) -
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License :
License Numb yz_ . / 000
Company'Name/Contractor Name: / e/
Address: w—
Expiration Date: '
ISignatur Telephone:
3.2 Registere Home Improvement Contractor.
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)?' Yes []No
Are you claming exemption from the requirements? ❑ Yes A No
If Yes, Go to Section 3.3
Company Name/Contractor Name: C /}C� /0�'� �! r�dv�j?�� i
Registration Number (if none, state "none"):
Address: g( Lam% S% o ✓f J 0 t�/ W D
Signature:' ele`phone.. I
Expiration Date:
3.3 For Reside lal 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, MA 02108, 617-727-8598
® 1 am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility 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 :#
610S.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July1, 1982, no individua `v
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building.
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 Constructioi
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 Homeowne
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 whit
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 tha
one hame 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
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3 � . s �� , f���ICOP;��
1: Date plan reviewed 3 0 2 H
2. DEFIED (see project review worksheet):
Date:
3. HOLD
Reason: �1�'�-�� Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: Date4UN 3 0 29
Applicant informed of above: Date:
Comments:
Time:
<�i Less Application Fee: $a?5 0(� Remaining Balance:
Total Permit Fee: $
Other $ Amount $3
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area -Alteration total sq. ft.
Permit Issued to:���(" s"
0 Approval in Part (Per 780 CMR.5911.93) f
Zoning Review: 5ignaturgt � � �f� Date:
Energy Report: Signature: Date'
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission; Signature: Date:
Other: - Signature: Date:
Brief description of work being performed: r lac-'e.p9cl�V /UCH
Side Yard
Year Built
Rear Yard
❑ Altering more than 25% per side of buildirng
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Dis osal System: Has application been submitted to the Historic Crommission?
❑ Municipal rivate Well ❑ Municipal i On Site Disposal System ❑ Yes ❑ No Date:
LJ CONSTRUCTION PLANS SITE PLAN LJ ENERGY
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