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2A Owner Record:
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Contact Address 'Phone Number
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Name (print)
2.2 uthorized A ent:
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Name (print)
Contact Add ess Phone Number
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3.1 Licensed Construction Supervisor/Specialty License . 1 .
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License Number:
Name: }
Company Name/Contractor
Address: 3&> Expiration Date:
Telephone.
Q',+ nature:
9 �
.._2Registered Home Improvement Contractor: Not Applicable II
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A.l e you a Home Improvement Contractor subject to (780 CMR.11 o.R6)? es El No
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A,! Y claming clamin exemption from the requirements? ❑ Yes ❑ No
If Yes, Go to Section 3.3
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Name/Contractor Name: _ � Registration Number (if none, state- "none"):
Company Ndm
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Address: I'Ilk� � 7
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iration Date: f
Tele hone: .. Expiration
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3_3 For. Residential Remodel Work Only
..UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
TING WITH H
F� Rso NS CONTRACTING
Cwrite:TJESTIONS OR COMPLAINTS call or.
Home Improvement Contractors Registration, One Ashburton Place -- Room 1301, Boston, MA 02108, 617: 727-8598
C� I any a Homeownerperformingall the work m self.
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Owners Name (print):
,:4,nature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
D ate:
3_4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONS-IBLE FOR THEIR OWN PROJECT
E1013.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
sh,-all -be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building.
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 Constructioi
Su-pervisors.
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 Homeowne
e; <<:iages 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 whit
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 tha
•
or►e home in a 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
*If new construction, please complete the following:
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, other (specify):
❑ 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)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
in nt. it-ZP-d work:
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Item Estimated Cost O to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
L:5. Total =(1 +2+3+4) F
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Signature of `Owner/Authorized Agent
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Date
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Page 4
MIT } �5U �
IffCAITO
Approval in Part (Per 780 C4R.511-1.13
COINZ5 I U..%�u I tuM PLANS
Lj.SfTE PLAN
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