BP-51107SIDENTIAL
:::
..- R Y OWNERSHIP/AUTHORIZED AGENT-
2.1 -Owner Record:
1A C3
Name (print). Contact Address.
Phone Number
.2 Authorized Agent:
Name (print)
Contact Address Phone Number
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3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor:
License Number.
Address:
C� Expiration Date:
...•
Signature: - • • • •Telephone.-- - • -
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3.2 Registered Horne Improvement Contractor: •
Not Applicable ❑
.� Are you a Home Improvement Contractor subject to(780-- ?P � CMR 0) . ❑ Yes 0 No -
.J If No go to the next section
Are you claming exemption from the requirements?. ❑ Yes ❑ N
If Yes, submit the required affidavit!
Company Name: - Registration„
Number (if none, state none ):.
L
Address:
Signature: Telephone: Exp
iration Date.
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CO - - NTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
. Home Improvement Contractors Registration., One Ashburton -
- 9' Place Room 130 1, Boston, MA 02108, 617-727-8598.
am a
Home
owner performi
ng all the work
P g myself. -
Owners Name (print): V V,
�A
Signiture: •
By signing the above, the homeowner acknowledges • • . - ges 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 PRO
JECT
109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0 effective July individual u y �, 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 Re
gulations for Licensing Construction
Supervisors.
� Exception: Any Homeowner performing work for which - -
P 9 ch 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.
F -
or the pu
rposes
ose � h s o this section
p p on only, a Homeowner' is defined as fo
llows: Person(s) who owns a
parcel
ei of land
which
ch he
/she
he res
ides
des or in
tends
ten ds tore res
ide,
eo nwh
ich
there is, or is intended to be, a one or two family dwelling, attached or detached structures accessoryto such use and/or farm structures. tructures. A person who constructs more than
one home in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
g -
Signature:
Your signature carries certain responsibilities, includin but • • P g not necessarily limited to, general liab�l�ty -
NOTICE TO LICENSED CONTRACTORS: The Buildin Code rovides -in the Rules •
g p es and Regulations section that an lic�
_ ens 9 ed A _ _ Y Constructlor
If new construction, please complete the following:
9
.Single Family: No. of Bedrooms 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
❑ Furnace (hot air) fuel gas (natural or propane), fuel oil, electricity, others eci
(P fY) ,
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
❑ Air conditioning - (separate unit)
0 None of the above to be provided
❑ Hot Water: Gas Electric uel Oil Other
Description of proposed work: Lo
� - .-.-
-r
STI MA.:
OSCONSRUCTI, CE }
Estimated Cost ($) to be completed by permit appliemnt
b. Total=(1+2+3+4) n 0
T SEC _
- ION
OWNERAUTHOR14��Tl
::.::-...1..:.h
:.: , -- - IX enSR',
:o- at�alies :for--.:-:.agentrconroretenowne
(Please Print)
js Owner of the subject property hereby authorize
to act on my behalf, in all matters relat'Vt ;Z horized by this building permit application.
Signature of Owner
D ate
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!OWN E RIAUT H -.
oRIZED
AGEHT.DECLARA
:ICAN
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�� *'�-@ �. a '^ , as OwnerlAuthorized Agent hereby declare that the statements and iinformation
on t e foregoing application are true and accurate, to the best of my knowledge and belief.
S'gned under the pains and penalties of perjury.
L Cf r
co
Date
Signature of Owner/Authorized Agent