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i�ESIi� =1ilTl�t_ NOTICE TO LICENSED CONTRACTORS: The Building Code. p o des. Iny licensed Construction
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Owner Record:
a�->trn yvr/t�
3Y 1Ve,1c,r,5 5Z!"y 0
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address _ Phone Number
�= SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
/
Licensed Construction Supervisor:
License Number: 6 5 % O
Address: (- r 7023
Expiration Date:
Y�j r /0200
Signature: Telephone:
3.2 Re stered Home Improvement Contractor: lG�' y / �f
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)?; ftYes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes No
If Yes, submit the required affidavit!
Company Name: 131-CIIq -S <�61
Registration Number (if none, state "none'):
13 `X 3 7
Address: ;�W- OA7a 3
Signature: Telephone: SvY-, 7-03
Expiration Date: vZ,
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
❑ 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.
Except1on: 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 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
Item Estimated Cost ($) to be completed by permit applicant
1. Building 3 �U
2. Electrical 3so
3. Plumbing f zov
4. Mechanical (HVAC)
5. Total = 0 + 2 + 3 + 4) y�', �5
(Please Print) (NI Mtt( �` v "✓i CJ ]j ,� ,
I, `1, , '. as Owner of the subject property hereby authorize J'c 4r14-
to act'
on fny behalf, inall matters relative to ork authorized by this building permit application.
l�
Signs ur , of Owner Date
`C �G f
y as Owner/Authorized Agent hereby declare that the statements,Fand information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains,, a J p nalties of perjury.
SIK
o Owner/Authorized Agent Date
CONSTRUCTION PLANS Alt SITE PLAN A ENERGY REPORT