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BP-46696RESIDENTIAL T GEN �` /AUTHORIZED A � 'SECTION 2 -PROPERTY. 'OWNERSHIP � ` \ r Owner Record: 2.1 O � , Pr I- e, -I -Mo -2 4, s� Contact Address Phone Number . Name (print) 2.2 Authorized Agent: ?/ Mle 7-5-7 ,73e9. 72J 2A, J Contact Address Phone Number Name (print) ... `,SECT ION 3 CONSTRUCTION:SERVICES CES 3.1 Licensed Construction Supervisor: Not Applicable ❑ License Number: Licensed Construction Supervisor: Expiration Date: Address: UJ Signature: Telephone: % 64-co� Not �Applicable ❑ 3.2 Registered Home Improvement Contractor: !L l� W des ❑ No C3 Are you a Home Improvement Contractor subject to (780 CMR- 6)? J If No, go to the next section! LL Are you clamingexemption from the requirements? ❑ Yes ®� If Yes; submit the required affidavit! a Name: Registration Number (if none, state „ none,, ).. company P y 0 Address: ' /3C Q / 7 Signa e: Telephone: OLIr - 77, Expiration Date: 1 3.3 For Residential Remodel Worky PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: nt Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598 Home Improvement ❑ 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 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. provisions of this section; provides that if a Homeowner Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the p P 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 E TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section th at any licensed Construction NOTICE 80 CMR R5.215) Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 7s P ' 152 ,_ M GL c ._- AFFIDAVIT § 25 _ INSURANCE AFF ( r ) - SU .:. :. .. ,. :SECTION 4--,W0 RKER S COMPENSATION IN Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to; [provide this affidavit i will result in the denial of the issuance of the building permit. Signed Affidavit Attached: 'es ❑ No ❑ Deck ❑ New Construction* (Energy report required) ❑ Addition (Energy report required) SECTION 5 DESCRIPTION OF PROPOSED.WORK(Checkafl applicable) ---= ❑ Repairs ❑ Accessory Bldg. (Shed/Garage) ❑ Alteration ❑ Chimney/Fireplace ❑ Replacement window/door No. of windows Doors *If new construction, please complete the following: Single Family: No. of Bedrooms No. of Baths �,/ fin /Sid in 'Roo � 9 g 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 ❑ Air conditioning - (separate unit) ❑ None of the above to be provided Electric Fuel Oil Other ❑ Hot Water: Gas ❑ i' Woodstove/Pellet Stove ❑1 (Other ((Specify below) DI'Demolition (Specify below) Description of proposed work: nj,5 i-ir3t,6. f rc k - K VJNVL Signature of Owner SECTION 6 : ESTIMATED CONSTRUCTION :COST Estimated Cost ($) to be completed by prarmit applicant Item _ Date SECTION 713 OWNER/AUT HORIZED AGENT DECLARATION ''� j�- , as Owner/Authorized Agent hereby declare that the staitements and information I, � on the foregoing application are true and accurate, to the best of my knowledge and belief. 9 9 PP Signed under the pains and penalties of perjury. Signature of Owner/Auth t Date We SECTION 8 INSPECTOR'S. REVIEWICOMMENTS 1. Date plan reviewed: 2. DENIED (see project review worksheet): 3. HOLD Reason: rev 4. HOLD subject to Zoning Board of ppea s a Comments: Inspector's Signature: Total Permit Fee: $ TOTAL FEE: Permit Issued to: Remaining Balance: $ Date: Date: Date: Date: �' Li `SECTIO" �0171�ICIEIINSPECTORS'NOTES `I Less Application Fee: $2 Other $ Amount $2 5 Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. - - .-:SECTION 11-ADDITIONAL`COMMENTS/SKETCHES 3() ❑ SPECIAL PERMIT (Per 780 CMR 111.13) $25.00 APPLICATION FEE IS NON ]ME-EITNDABL]E & NON-TRANTSIFEnABLE .-=,r- P-L-©AmTE; RECEIVED Energy Report: Fire Clef: oard of Health: Conservation Commission: Signature: Date: Signature: Signature: Signature: Deate: D,�te: D -3te: Other: Signature: Deate: Brief description of work being performed: 6J x , ed7 C 1.1 Property Address: Nearest Cross Street: Subdivision Name: Total Land Area Sq. Feet: .:SECTION 1 SITE INFORMATION 01-to )39cc FX, P D 1.4 Water Supply (MG;Xrrivate : ❑ Municipal Well 1.2 Assessors Map & Lcit Number: Map Lot 6 K. 1.3 Historical District ❑ Yes ❑ No Has application been R;ubmitted to the Historic Commission? ❑ Yes 1.0 Nc:) Date: 1.5 Sewage Disposal S%; stem: ❑ Municipal 111 n Site Disposal System ❑ CONSTRUCTION PLANS SITE PLAN ❑ F.NERGY REPORT