BP-36986RESIDENTIAL 2004 RESIDENTIAL 2004
2.1 Owner of Record:
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Nam (print)
2.2 Authorized Agent:
Name.. (print)
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Contact Address
3.1 Licensed Construction Supervisor: Not Applicable ❑
Liceinsed Construction Supervisor License Number
Address Expiration Date
Signc;.ture Telephone
3.2 Registered Home Improvement Contractor: Not Applicable ❑
Are 'vou a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no, .go to the next section! '
Are �fiou claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
0
Phone Number I
Company Name Registration Number (if none, state ❑ none❑)
Address
Sign, .ture Telephone Expiration Date
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
Own(pro
.,rs Name t)
Sign�:ture
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
10'9.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1,1982, no individual
shall ble 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
Const-~uction Supervisors.
Exc option: 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 t"ian one home in a two-year period shall not be considered a Homeowner.
If you .are applying under thi sectio sign elow:
Signar .ire: -
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
Workers Compensation
Insurance affidavit must be completed
and submitted with this application.
Failure to provi0e this affidavit
will result in the denial
of the issuance of the building permit.
Signed Affidavit Attached:
❑ yes ❑ no
/ -& 7!�& � - 4^ ?3
1 R»ildinor
� .,00�0&2�
(please print)1W as Owner of the subject property hereby authorize
to act on my behalf, in all matters ', a iv t� ork authorized by this building permit application.
Signature of Owner
Signature of Owner/Authorized Agent
Date
1
DatFp
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Rev. January 1, 2003
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RESIDENTIAL 2004
❑ FOUNDATION ONLY
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,/RESIDENTIAL
❑ FOUNDATION ONLY
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