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BP-38834�._,mc •G,�S L C� E CCORD PLAN n y Of This Endorsed 1 Plan east Be Kept On Site During en tr�i�tion 1 Date r IV SONO-TUBE VIZE AND hp�i INSPEanON tS ri zou3r,,r-60,r� THE CONWETE IS F;UR . BUILDING DEPARTP �17: ® .UJ J 10FILE,ffi i - .�vrm�}.x+.-�.e.T".._ _...:r"�•.e.<ve -... ; -sw q. -T^T"" �_ '."`_ �!-Y.....y��w•..1 ..r-ec.,+-fY'nev,�r�.. .e.��.�ae.......ean»�..n...n ,�T i.Y..r."r{.: Tf�_.T T. • .T'.�11 `rA. . � ♦ .a '\. .. . � �, - .. .. - - RESIDENTIAL feri d% 1 Owner of Record: g l i Name (print) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number S G x,.¢ /// s a, i 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 For Residential Remodel Work Only PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: ti-ESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598 RESIDENTIAL ❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑] woodstove (energy report required) (energy report required) fireplace ad-eck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑l demolition (shed/garage) no. of windows_ doors_ (specify below): (slpecify below): * If new construction, please complete the following: Single Family: no. of bedrooms no. of baths Two Family: no. of bedrooms unit I 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 ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: w 0) CA C) -z-- a cA' ` ��C✓C� C7C� Item ` Estimated Cost ($) to be completed by permit applicant, Owners Name (print - - - ry _ 4. Mechanical AC Signature — 5. Total = (1 + 2 + 3 + 4) by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund * Estimated Total $ �5 0 D D. — 1 1-1 '� Mil rr Date / s z �I✓C�z ��....awhl�x A a z'it tQ ......,. � ,., �. � �u ., � ��:„: g pp r .4 Homeowner Exemption One &Two Tamil ` Only ;__ � .. a , FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT (please print) 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 I, , as Owner of the subject property hereby authorize shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elementso£buildings to act on my behalf, in all matters relative to work authorized by this building permit application. 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 Signature of Owner Date engages r ... e, s a person(s) s for titre to do such work that h Homeowner h 1L t . . g g p O such shall act as supervisor. ,. b i� C l... a y a ,,� t 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 x s„ _ there is,; yr 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. I, L) -c- Y--� as Owner/Authorized Agent hereby declare that the statements arrld information odithe foregoing application are true and accurate, to the best of my knowledge and belief. If you are applying underthissection sign below: SignatureSigned under the pains and penalties of perjury. Your signature carries certain responsibilities, including but not necessarily limited to, general liability- Signature of Owner/Authorized Agent Date., C:\bldg.foarms\Bldgapp.res.wpd Page 2 Rev. January 2005 C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January 2005 I RESIDENTIAL RESIDENTIAL ❑ FOUNDATION ONLY $25.00 APPLICATION FEE I5 NON -REF �c N KABLE NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑l no 1.2 Assessors Map & Lot Number: 1 Property Address: Map__f-7,5-- Lot e -_ Nearest Cross Street: b r r� t 1 C Subdivision Name: 1.3 Historical District ❑ yes ❑ no Total Lance © Sq.�: Has application been submitted to the Histroric Commission? - . ❑ yes ❑ no Date: .4 Water Supply (MGL c 40 § 54): 5 Sewage Disposal System: C:Vdg.forms�Bldgapp.res.wpd Page 4 Rev. January 2005 Cc\bidg.forms\Bldgapp.res.wpd Page F Rev. Janua �005