scan 003RESIDENTIAL 2000
.............................................
........................ .......................... ... .... .........
............
............. ..... ...........................
.... ....... %' ................................
....... . ... . ... ....................... ...........
........ .... :_:-:-:-:_:_:_X_X-X - ..-:
... .............. ....... ........ ........... ........ ...........................
........................
tairnolttz
....... ...... ....
.....................................
2
F2.Owner of Record:
Ike
Ave
0 CCDA v
Name (print) Contact Address Phone Number
fAuthorized Agent:
Name (print) Contact Address Phone Number
>� R ..�. N �E �T f3ES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor License Number
Address Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Are you a Hom � Improvement Contractor subject to (780.s.`CMR-6)? ❑ yes ❑ no
If ft, o, go to the next section!
s
Are you c i aim in cr exemption from the requirement? :; " ❑ yes ❑ no
{` If yes, submit the
required affidavit!
Company Name
Address
Signature Telephone
3.3 For Residential Remodel Work O y
Not Applicable O
Registration Number (if none, state "none")
Expiration 1 ration Date
PERSONS CON t RACTING WITH GISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Inzp rovement Contractors Registration, One Ashburton Place -.Room 1301, Boston, MA 021089 (617) 727-8598
4
Owners Name (print)
Signature
by
signing the above th
e home owner acknowledges
wledg
es th
at there will b e no
e li iit
ty
to the Guara
nty
Fund
nd
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 Licensi-ng 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 structu.,-es, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing
Construction Super-i7isors.
Exception:
An Homeowner
performing work
for which a Buil
ding ing Pe
rmit is required
uired sh
all
all be exe
mpt t from the
provisions ions of se
ction; n,
pro
vides es that if a Homeow
ner r
engages a persons) 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 'r%vo-year period shall not be considered a Homeowner.
If you are applying -und 1his section sign below:
S i nature:
Y r signature carries certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL
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 R5.2.15W v C
V Z.
.........................
....... ........ ------- ....................
....................
.. . . . . . . . ... . . . . . . . . . . .. . . . . . . . . . ...... .... 30 .:. . . . . - 5 ......... . . . . . . . . .
- - -C .. . . - -N - V-1,
.0 rZ X 0 M 0.
:::.:i * '32:`
.................................. .. ..... ...................
........ ........... WA
........... P.
E. T1 te
4 .... . R S.. ......
.................... ...............
................
st be completed and submitted with this application. Failure to provide this a;�fidavit
Workers Compensation Insurance affidavit mu
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes no
..........
..... .....................
............... .
FT
Oov .....
.......... ......... :diva d
. ... . ....
..................... .. ..
.. . ... . ............
.......................................... .....
.
O Es
new construction* ❑ addition ❑ alteration ❑ repairs O chimney/ O woodtove
(energy report required) (energy report required) fireplace
O deck 0 pool D accessory bldg. ❑ replacement window/door JDet`1111111'1r 0 demoliition
(shed/garage) no. of windows doors (specify below): (specify b)elow):
* If new construction, please complete the following:
Single Family: no. of bedrooms 3 no. of baths
Two Family: no. of bedrooms unit 1 no. of baths unit 1
/ no. of bedrooms unit 2 no. of baths unit 2
d Furnace (hot air) -fuel gas (natural or propane) fuel o' ,electricity, other (specify):
❑ Boiler (heating) -fuel gas (natural or propane), fue oil, electricity, other (specify):
o HVAC (combined unit) -primary fuel, natural gas, propane, electricity, other (specify):
a Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: �����0 •� �j,�tli�,
U...................
........ . ..........................
U. VT 0
................:.:.�::::::::::::::::.�.�...................:.:.:.�.�.� SIMAIT
G'��£�1!�::::�r:E..�'. STR f N
T................:::::::::::::::::......................:::::.:::::.�:::::::..................::.::::::.::..............:::.::::::::................................
....................... Item M P Y P PPEstimated Costt� be completed b permit applicant
1. Building
2. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (l + 2 + 3 + 4) *Estimated Total $ � zoo
....:............ ON
.......
�:........
h�w::::...
44,
:...:�:.::�
....
:�:��:�ad
>�ease 7pr'nt)
as Owner of the subject property hereby authorize �'v ✓z-t
to act VIny bepalf, in all matters relative to work authorized by this building permit application.
b fZ010-13
Signature of O er Date
.... ...... . X � ....... - 7 t: N �A
L -..I-
on V c� � O�l�; as Owner/Authorized Agent hereby declare that the statements and infoj; oration
the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner
thorized Agent
Date
«lin\forms\bld£pp.res Page 2
c:\wpRev. January 20, 2000
c:\wpwin\forms\bldgapp.res
Page 3
Rev. Jannuary 20, 2000