BP-17780RESIDENTIAL
2000
RESIDENTIAL 2000
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2.1 Owner of Record:
ame (pW int)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
.. .:....:.;:;;;:.;:.;.:.
GNSTRUC?EIGN SEit <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")
Midress
Signature Telephone
iration Date
Expiration
3.3 For Residential Remodel -Work Only
PERS 8 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 govemed'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 car 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 hvo family dwellins, attached or detached structures accessory to such use and/or farm structures. Aperson who constructs more
than one home in a two-year period shall not be considered a Homeowner.
If you are app y ng u thi ection ' b oN .
Signature
Your signature carr s certain responsibilities, including but not necessarily limited to, general liability
NOTICE To LICENSED CONTRACTORS: The Budding Code provides in the Rules and Regulations sectionthatan y licensed Co nlstructton
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.I1e5)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to proviide this:affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑
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t2ES.CRf 11 N::4�F I ROPOSI D�'V(1RXXXXI Ieheck aI appi>«��Ie�
_ .
.... .
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/
1200dstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory b ld . -❑ replacement window/door ❑othere
10 demolition
(shed/garage) no. of windows doors (specify bow):
((specify 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:
SEC Ifli' > I STIhM`I DGONSTI-C`I-ION:.�fl�T'�....
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildin: _
2. Electrical
3. Plumbiniz
4. Mechanical HVAC
5. Total = (I + 2 + 3 + 4)
* Estimated Total $
1
{ lea,� pri t)
I, `GIJ�•��,as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent hereby declare that the statements atnd information
on tt e foregoing application are true and accurate, to the best of my knowledge and belief.
Signed un," th ains a pe s of perjury.
l
Sigt}tture wner/Authorized Agent lane
P ? Rev January 13. 2000"
('°\hlria fnrmc\RldPann rez wnd
Page 3
lRev. January 13, 2000
2000 RESIDENTIAL 2000
O
... .. O WDATION ONLY
RESIDENTIAL
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:.:... INSPECTUTt s R>rvf�
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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): Date:
5. DENIED (see project review worksheet): Date:
6. HOLD reason: Date:
7. HOLD subject to Zoning Board of A eals action: Date:
8. - Coments: %;676
mi ®J�
,`,
,
•' - O _
9. Ins ctor s St natur e.
P g gal: 2000
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