HomeMy WebLinkAbout0210 BUCKWOOD DRIVE ;i- ,
--
I
CRE
SHE SS PERWjwn of Barnstable *Permit#
OF
Fapir m th issue date
MAY 16 2012 Regulatory Services F
M" $ Thomas F.Geiler,Director �' v
Ago OF SARNSTA13LE
Building Division. _
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address �� y �Z 11)GG
residential Value of WorR G� Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address ink P
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑Aam a sole-proprietor -
Er I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy# ,
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof.(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping., Going over existing layers_of roof)
❑ Re-side
#.of doors
.placement Windows/doors/sliders.U-Value I (maximum.35)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License-&Construction Supervisors License is
required.
SIGNATURE:
T
Q:\WPFIL.ES\FORMS\building permit forms\EXPRESS.doc
Revised 051811
The+C'ommanw ealth of Massachusetts
Deparrhuent of1ndus&ia1,4ccidmft
Far Ot7ffwe`efInvestigations
600 Wask ngion,Street
Boston,MA 02111
n mamgov din
Workers' Compensation Insurance Affidavit:BmtderslGDntractur.s Electricians,/Plumbers
Applicant Information Please Print Lei bly-
N sroi hral):
Address: c, AlU90C�V Q'2
CitylState Zip- *\,A 6Q I Phone#: 5�g� ?5 a�
Are you an employer?CAeck the appropriate boa: T of ro reject r
�. I am a contractor and I 3'P'e P i ( ���-
I.❑ I am a employer with ❑ 6_ ❑New construction
employees('full andVorpact-time).* have hiedthe sub-contracton."
2..❑ Lam a sole proprietor or pares- listed on the attached sheet. 7- EI�.odeling
snip and have no employees. These sub-contractors have 8_ k&Mlifion
employees and have woAers'
wa>:lting far the in any capacity. 9_ El Building addition.
o workers' _insurance comp.���$
re rkers'required. 5. ❑ tide are a corporation and its 16.0 Electrical repairs or additions
officers have exercised their
3. ama homeowner doing allwntk 1I.0 Plumbing repairs or additions
> of per MGL
myself.[No wculaers .comp- exemption P 12.❑Roofrepairs
insurance r &]S c.152, §1(a�and we hwie,no
employees_[No workers' 13.0Other
comp_insee required_]
aPPhc that checks boc#1 mins''also fill out this section below showing their workers compensation policy informaahm
Hameo�vmers who submit this d8dam i;m&cxtmg they ate doing all work and then hue outside canuxims mast submit a new affidnwit indicating suck
tContractors that check this box roust attached an additional shot showing the name of the sub-sauna m and:stue whets ornot those entities hire
emrphryees. If the.sub-contmCaFs hm employees,dLey must provide their workers'comp.policy number.
I am ant empla)w M&is pr mid&g workers'compensation,imurance for sty emgdojwm Below is the poUcy sad jolt site. ,
information.
Insurance Company Nam:
Policy#or Self-ins_Lic.#: F,xpiration Date:
Job Site Address: City/StatelZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number.and expiration date).
Failure to secure:coverage as required udder-Section 25A of MGL c_ 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine
of up to$250.00 a flay against the isolator. Be.advised that a copy ofthis statement may be forwarded to the Office of
Investigations of the DIA for itLsursace coverage verification.
I+do hereby carhfy under tppa9s aced pentahYes of peditty that the information peed above is true and correct
Si Date:
Phone#:
Official use only: Do not write in this area,to be completed by city or town a icial'
City or Town.: Permit/License#
L-muing Authority(dreie one):
1.Board of Health 2.Buffing Department 3.CitylTown Clerk 4..Electrical Inspector S.Plumbing Inspector:
6.Other
Contact.Person: Phone 9:
6
• snatvsres[E +
,.� 'own of Bar0stable
rEo�rA ;
Regulatory Services
Thomas F.Geiler,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA,02601
: www.town.barnstable.ma.us
Office: 508-862-4038 Fax; 508-790-6230:
Property.Owner Must
Complete and Sign This Section
If Using A Builder
I, as.Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
:
(Address of Job)
Signature f Owner Date -
Print Name `
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the e
reverse side.
Q:IWPHLESTORMSUilding permit formsEXPRESS.doc
Revised 051811
�t Town of Barnstable
Regulatory Services
'"RNST"MMAM Thomas F. Geiler,Director
pr ;or►``� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number �^) '� street —7 (j village
O 4�
"HOMEOWNER": c k-,j ( �4 �F—d
name t a` . home phone# work phone#
CURRENT MAILING ADDRESS: qto Q
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
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 a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section
109.1,1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
Signatfire o Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION -
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as"supervisor.
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form.currently used by several towns. You may care t amend and adopt such a form/certification for use in
your community.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 051811
?, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Z1110(0 Parcel Permit#
Health Division .?' e04&7L'5 4? d7 ` Date Issued
Conservation Division Fee s6
Tax Collector SEPTIC SYSTEM MUST BE
Treasurer C INSTALLED IN COMPLIANCE
WITH TITLE 3
Planning Dept. `-:ENVIRONMENTAL CODE AND
Date Definitive Plan Approved by Planning Board . TOWN REGULATIONS
Historic-OKH Preservation/Hyannis
Project Street Address 10 �(3 6 )00 0 V2_
Village 1�`f W vV tS
Owner M A4y 1�>u✓Nke Address
Telephone l yS o
Permit Request XNO 0 I., 1 0
Square feet: � existing proposed 2T 2nd floor: existing proposed Total new
Estimated Project Cost Zoning District Flood Plain Groundwater Overlay
Construction Type U-50a%o
Lot Size f 0 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ff Two Family ❑ Multi-Family(#units)
Age of Existing Structure ac) Historic House: ❑Yes Flo On Old King's Highway: ❑Yes la-M
r Basement Type: 0161-1 ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 6 UE —
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing new
Total Room Count(not including baths): existing . new First Floor Room Count S
Heat Type and Fuel: Cf Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes Fireplaces: Existing �' New Existing wood/coal stove: ❑Yes 6o
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded Cl
Commercial ❑Yes 90 If yes, site plan review#
Curfnt Use Proposed Use �,o ..
�11 BUILDER INFORMATION
Name -Telephone Number
Address vv License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO o c.u✓L �_\`fit 1 �4%
"k,., L \
SIGNATURE DATE 6LIOf'OC)
FOR OFFICIAL USE ONLY
YI✓RMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE '
OWNER
DATE OF INSPECTION {
FOUNDATION `7
FRAME ..
INSULATION AlNlot
FIREPLACE T�3 '
ELECTRICAL: ROUE � '�" FINAL
!V ,
PLUMBING: ROLA "Q IT FINAL f
d'� h )W7
GAS: ROU.GHO FINAL
FINAL BUILDING
ax
DATE CLOSED OUT ;
ASSOCIATION PLAN NO. a
r
f•
12`
/,VSc,lktl�,i
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r, ZXE3
2x 8 ��— --
Ty�aQ }iousF wiZAP
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MAP 27:1-t: , — - --, ----
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l MAP 71
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AP 71 \ 4
.
63 .
P271
790 CMR Appaxda 1
Table JS=b(coatiaaeQ Hated with Fossil Fuels
Paelcaga for Oae and Two-Family Residential Baildinp
MINIMUM
Hening/Cooling
Glazing 1
MAXIM CeiiiaB Wall , Floor " P Egaip.= E ci
Arcs'(Y•) U-value R-vsia� R•valnie R value' R valaes R-vui'
Package SMI to 6M Heating Degm Daya'
13 19 10 6 Normal
Q I2% 0.40 33 19 19 10 6 Normal
R 12% 032 30 I3 -19 � l0 6 ES AFUE
9 12Y• 0.50 WA N/A Normal
13 25T 1SY. 0.36 3E 19 19 10 6 Normal
U I5% 0A6 33 _ NSA ES AFUE
V !S•/. 0.44 3a 13 25 N/A ES AFUE
19 19 10 6
W 15% 032 30 13 � N/A N/A Normal
X I S% am 3a N/A N/A Normal
19 ?3 90 AFUE
y 18•/. 0.42 31< 19 ip 6
Z 19% 0.42 3t 13 90 AFUE
AA I S•/. . OSO 30
19 19 10 6
I. ADDRESS OF PROPERTY:
---------------
2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS:
3. SQUARE FOOTAGE OF ALL GLAZING: S� �T
4. %GLAZING AREA(#3 DIVIDED BY#2):
S. SELECT PACKAGE Q
AA-see chart above):
NO
TE: OTHER MORE INVOLVED MMODS OF DETERMINING ENERGY REQUIREMENTS r
ARE AVAILABM ASK US FOR THIS INFORMATION.
BUILDING INSPECTOR APPROVAL:
NO:
YES:
• q.{amu-f980303a
780 CMR Appendix J
Footnotes to Table.Z.2.1b: ng s
assemblies (inc
doors, skylights, and
' Glazing area is the ratio of the area of the glazing grossdoors) to the wall
basement windows if located in walls that enclose co�nditionede, but excluding a m Y be excluded udedofromu the U-value requirement.
area, expressed as a percentage. Up to 1/o of the to glazing
areFor example,3 it' f decorative glass may be excluded from a building design with 300 ft of glazing area.
e with'
' After January 1, 1999, glazing U-values must be tested and ° orntaken from Tabl by the e JJI-5..3a. Ucturer in cvaludes care for
the National Fenestration Rating Council (NFRQ test procedure,
whole units: center-of-glass U-values cannot be used.
The ceiling R-values do not assume a raised or oversized trams C0R30insulation may beon. If the tsubstitut d for R 38
insulation thickness over the exterior walls without compress '
insulation and R-38 insulation may be substituted for R49 insulation. Ceiling R-values represent the sum of cavity
insulation plus insulating sheathing Cif
used) For ventilated ceilings, insulating sheathing must be placed between
•
the conditioned space and the ventilated portion of the roo£
`Wail R-values represent she semi of the wall cavity insulation plus insulating sheathing (if used). Do not include
exterior siding,structural sheathing,and interior drywall.For example,an R 19 requirement could be met EITHER
plus R-6 insulating sheathing. Wall requirements apply to
by R-19 cavity insulation OR R I3 cavity insulation P ons,but do not apply to metal-frame construction.
A wood-frame or mass(concrete,masonry,log)wall constructi such as unconditioned crawlspaces, basements,
The floor requirements apply to floors over unconditioned spaces
or garages).Floors over outside air must meet the ceiTmg requirements.
`T}:e entire opaque portion of any individual basement wall with a o depth iiings gigs doors of conditioned
the=t the same R-value requirement as emg
above-grade walls requirement
bz.iements must be included with the other glazing. Basemecit doors must meet the door U-value
d-scribed in Note b.
The R-value requirements are for unheatedis additional
approach 3�4, or 5. if you plan to install more
utilizes electric resistance g e Iowest
building uuI t with th
If the g equipment men
than one piece of heating equipment or more than one piece of cooling equipment, the q p
efficiency must meet or exceed the efficiency required by the selected package.
For Heating Degree Da requirements ents of the closest city►or town see Table J5.2.la
NOTES:
. acceptable levels.Insulation R values are minimum acceptable levels.
a)Glazing areas and U-values are maximum
R-value requirements are for insulation only and do not include structural components.
ested
b) Opaque doors in the building envelope must have a U-valuNe noCgre step than lure or-taken from the door.35. Door U-values mustU-value
and documented by the manufacturer in accordance with the
rating for that door is not available, include the
in Table J1.5.3b. If a door contains glass and an aggregate
glass area of the door with your windows and use the opaqu
e door U-value to determine compliance of the door.
One door may be excluded from this requirement(Le may have a U-value greater than 0.35).
c) If a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with
different insulation levels,the component complies if the area-weighted average comply if the ue area-weight d averager than or l to
the R-value requirement for that component. Glazing or doorcomponents
value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors).
43
The Town. of Barnstable
F1HE l
Department of Health Safety and Environmental Services
Building Division
BMWSrABLE, ' 367 Main Street,Hyannis MA 02601
MASS.
9� 1639. 10g'
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: ;ore UC k U_. (7 O(7) 1 l VZ
number -- + street vil ge
W"HOMEONER": ma /e� i,,eIG 7 5 EOS�
name home phone# work phone#
CURRENT MAILING ADDRESS: 60u!C_
city/town state zip code
The current exemption fdr"homeowners"was extended to include owner-occupied dwellings of six units
or less and to allow homeowners to engage an individual for hire who does not possess a license,provided
that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
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 a two-year period shall not be considered
a homeowner. .Such"homeowner"shall submit to the Building Official on a form acceptable to the
Building Official,that he/she shall be responsible for all such work performed under the building permit.
(Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and
other applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building
Department minimum inspection procedures and requirements and that he/she will comply with said
procedures and requirements.
Signature of Ho eowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply
with the State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the
provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a
person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see
Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in
serious problems,particularly when the homeowner hires unlicensed persons. In this case;our Board cannot proceed against the
unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit
application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a
form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community.
Q:FORMS:EXEMPTN
�t The Commonwealth of Massachusetts
{ _ = Department of Industrial Accidents
�- ___ � __ Office ollmrestigalioQs
600 Washington Street
' - f Boston,Mass. 02111
Workers' compensation Insurance Affidavit
name' t.
location'
hone#
city
UA $
I am a ho ow=pig all work myself.
I am a sole v new and bm no one cvorkin az�v %//%///////%//////%/%/%/%//%/%%%%%/�///%�%////
%�//%//%/%/ loyees working on this job..
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insurance-co two
S2,Soo.00 and/or
r: of erimutal penaltin of a Erse up
Faihtre to secure Coverage n required under Sedia�l3A of M a L4 WOR to the �O�e of 5100.00 a dsy against me. I understand that a
one years'imprisonment as Mn as cha penald"in the foam of:STOP WORE ORDER and
copy of this statement may
be forwarded to the OM=of hn of the DIA for coverage verlficatloa
end in ofPerjury that the information provided above is true and correct
I do hereby certify under the p ' p
`-- tE Date (D J 1,O O -
Si_cnature 2A �—b
#
Print name
�2 �� phone
loop MONINIM010
oincw use only do not write in this area to be completed b7 city or town
official
perudt/license# • QBuading Department
city or town: QLicensing Board
QSeiecunen,s office
Q check if immediate response is required QHealth Department
phi#*1 ❑other
contact person:
MIMI
(trnud 9/95 PJN
Information and Instructions
chapter 152 section 25 requires all employers to provide workers' compensation for their
Massachusetts General Laws p person in the service of another under any con==
employees. As quoted from the"law",an employee is defined as every
of hire, express or implied, oral or written.
corporation or other legal entity, or any two or more of
An emvloyer is defined as an individual,partnership, association, rP
in a Dint enterprise, and including the legal representatives of a deceased employer, or the receiver or
the foregoing engagedJ to employees. However the owner of a
trustee of an individual,partnership,association or other legal entity, emp Ymo�P Y house of
dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling grounds or
ersans to do maintenance constivction or repair work an such dwelling house or on the
another who employs p be deemed to be an employer.
building appurtenant thereto shall not because of such employment
152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal
MGL chapter in the commonwealth for any applicant who has
of a license or permit to operate a business or to construct buildingsthe
produced acceptable evidence of compliance with the insurance coverage required.
fo��nall , ne ie until
not pro P an contract forthe p of
commonwealth nor any of its political subdivisions shall enter into Y have b resented to the contracting
Rance with the insurance of this chapter been P
acceptable evidence of camp .
authority. ON /
22MMEM
Applicants
and
ensation affidavit completely,by checking the box that applies to your situation
Please fill in the workers cis and
P���alam�g with a certificate of insurance as all affidavits maybe
supplying company names, won of insurance coverage. Also be sure to sign and
submitted to the Department oi.tom that the application for the permit or license is
date the affidavit. The affidavit should be red�ed to the city "law"or if you
being requested,not the Department of Industrial Accidents. Sou hld youhave any questions regarding the
at the member listed below.
are required to obtain a workers' compensation policy,please call the Department
City or Towns '
fete and printed leg1ly. The Department has Provided a space at the bottom of the
Please be sure that the affidavit is come has to contact you regarding the applicant. Please
affidavit for you to fill out in the event the Office of numb �er. The affidavits may be ret to
ens
be sure to fill in the pc6*Aice number which will,be use ce
d as a referen
the Department by mail or FAX unless other arrangements have been made.
Office of investigations would like to thank you in advance for you cooperation and should you have any questions.
The t�
please do not hesitate to give us a call.
%E /
The Department's address,telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Omce of IngestlDetions
600 Washington street
Boston,Ma. 02111
fax#: (617) 727-7749
phone#: (617) 7274900 eat. 406, 409 or 375
The T o Wn o a
LMA-'; B ' ' • Department of Health Safety' �d Environment I Services
9 •"' 9. $ P Building Division
367 Main Street.Hyannis MA 02601
Ralph C:csser
Building CJIS�
Office: 508-862-4038
a:=-
pax: 508-790-6230
Permit no. -
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERNRT APP1ICATION
iterations.renovation.repair.modernization.conversion.
MGL c. 142A requires that the"reconstruction. owner-occupied
improvement,removal,demolition•or construction of an addition or pre-existing�which owns adiacent to
building containing at least one but not more than���ng�Certain exceptions,along with other
such residence or building be done by registered
requirements.
_EsEs
ti nated Cos
Type of Work:�
Address of Work: 211 7
y M S� _G '2 /
to 2
pwner's Name:
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law '
Q3ob Under S1.000
[]Building not owner-ocupied
0ge er pulling own p=
Notice is hereby given that: OR DEALING WITH UNREGIS•rERED
OWNERS PULLING THEIR OWN PERNIIT VEMENT WORK DO NOT HAVE
CONTRACTORS FOR APPLICABLE HOME G F[TND UNDER MGL c. 142A.
ACCESS TO THE ARBITRATION PR _
SIGNED UNDER PENALTIES OF PERIURY
I herebv apply for a.permit as the agent of the'owner:
' Registration No.
Contractor Name '
Date
OR
Owner's Name
±i—'
Date
ESTIMATED PROJECT COST WORKSHEET
Value
LIVING SPACE
(high end construction) square feet X$115/sq. foot=
(above av�construction) 0 /-6 square feet X$96/sq. foot= 2g. '71
square feet X$57/s foot
(average construction) q q•
GARAGE (UNFINISHED) square feet X$25/sq. foot=
PORCH square feet X$20/sq. foot=
DECK square feet X$15/sq. foot=
OTHER square feet X$??/sq. foot=
Total Estimated Project Cost -
c
IAHFORM 1/3/00