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BP-38420R F.QtMF.NTTA T . RESIDENTIAL r,0: 2.1 Owner of Record: s --u SOUS7f 3 Pfg40 0/4 s©g)q 5a`l�y 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, MA 02108, (617) 727-8598 �)waers Name (print �ign2tur , by si 'ng the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund `% � v Q�✓-' Date� 3.4 Homeowner Exemption - One & Two Family Only FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 10�.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 ofbuildings or struyctures, 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. Exiteption: 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 engagos 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 fann structures. A person who constructs more than one home in a two-year period shall not be considered a Homeowner. If you are applyi nder this section sign below: Signature: A=` You ignature 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 R5.2.115) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to prolvide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached:° ❑ yes ❑ n 0 ❑ new construction* ❑ addition ❑ alteration ❑ p airs chimney/re ❑ El woodstove (energy report required) (energy report required) fireplace ❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other [❑ demolition (shed/garage) no. of windows doors (specify below): ((specify below): * 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 I 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 ❑ Hot Water: Gas Electric Fuel Oil Other Briefpescription of Proposed Work: Item Estimated Cost ($) to be completed by permit applicaitt 1. Buildin 2. Electrical 3. Plumbina 4. Mechanical HVAC 5. Total = (1 + 2 + 3 + 4) *Estimated Total $ C:\bldg,forms\Bldgapp.res.wpd Page 2 Rev. January 2005 t :\niag.rorms\rsiagapp.res.wpa Page 3 Rev. January 2005 RESEDENTUL ECII91� INNSPCTOI2'IZE%I�ICt31�IlYI 1. Date plan reviewed: 2. DENIED (see project review wo-ksheet): Date: 3. HOLD reason: 4. HOLD subject to Zoning Board of Appeals action: Comments: Dater ENTIAL ❑ FOUNDATION ONLY C:\bldg.forrrs\Bldgapp.res.wpd Page 4 Rev. January 2005 CAbldg.forms\Bldgapp.res.wpd Page i IR�January200�5 ^\