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RESIDENTIAL 2001
RESIDENTIAL
2001
SECTION 2 - PROPERTY OWNERSMP AUTHORIZED AGENT
2.1 Owner of Record:
5� L°�.5 �-
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
�-Sa C°VIrPs'�� Mt WMRib'jAa,
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number
Address O
Expiration Date
GISIAO
Signature Telephone
$
3.2 Registered Home Improvement Contracto .
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, MA 02108, (617) 727-8598
Owners Name (print)
Signature
_
by signing the above, 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
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
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 780 CMR R5.2.15)
SECTION 4 WORKER'S COMPENSATION INSURANCE AFFIDAVIT. (MGL C 152 § 25)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide thhis affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: es ❑ no
• ; SECTION 5 -DESCRIPTION OF PROPOSED WORK (check all applicable) ..
new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ wc3odstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ dermolition
(shed/garage) no. of windows doors (specify below): (speciffy below):
* If new construction, please complete the following:
A /
Single Family: no. of bedrooms 3 no. of baths 1)J
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), el `oi , 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
Hot Water: Gas Electric Fue\O��, Other
Brief Description of Proposed Work:-�, at 2SCo5�i Cs3� eksalN STi :
'�T 1NN
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SECTION - 6 ESTIMATED CONSTRUCTION COSTS -
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildinty
. A 1 co,
2. Electrical
Gco� r(m
3. Plumbin
r1
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $ V- 96
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please Drint)
as Owner of the subject property hereby authorize
to t on y be , I 1 matte relative to work authorized by this building permit application.
��,�� 1A , 2�01
Signature of Owner Date
E TI
B - OWNER/AUTHORIZED AGENT DECLARATION
uthorized Agent hereby declare that the statements and inforrmation
a OwPest6of
on the foregoing application are tr and accurate, to the my knowledge and belief.
Si under the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date
L , C:\bldg.fomis\Bldgapp.res.wpd Page 2
U
Rev. January 19,2001 C:\bldg.forms\BldgapD.res.wnd
RESIDENTIAL
2001
SECTION 8 -INSPECTOR'S REVIEW/COMMENTS
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):
5. DENIED (see project review worksheet):
6. HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
9. Inspector's Signature:
Date. 01
SECTION 9 - APPLICANT NOTIFICATION
pP � Time: Clerk:
Applicant info ed of above Date:
Comments:
S CTIO 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ 25.00
Remaining Balance:
TOTAL FEE: �; j Gross Area -New Construction total sq. ft. C;L
Gross Area= Alteration total sq. ft.
Permit Issued To ��� _ �. ��� X <�-elf.
SECTION 11-ADDITIONAL COMMENTS/SKETCHES
a
C:\bIldg.forms\Bldgapp.res.wpd Page 4
i
Rev. January 19, 2001
s
❑ Municipal) Private Well I ❑ Municipal KOn Site Disposal System I -
:\bldg.forms\Bldgapp.res.wpd Page 1 Rev. January 19, 2001