Section 1

Town Ashfield Bernardston Buckland Charlemont Conway Erving Gill Hawley Heath Leverett Leyden Shelburne Shutesbury Whately Site Address

Owner Name Mailing Address:

Owner Telephone #( H) (W) (Cell)

Contractor Contractor Address

CSL # Exp. Date Hic # Exp. Date

Cont. Tele# Fax E-mail

Est.Cost Sq.Ft.Living Space(New) Sq.Ft. Other Space(New

Obtain these signatures (where applicable) BEFORE submitting this application:
Fire Chief:______________________________________________Date______________ 
(Only with bedroom addition)
Board of Health: ________________________________________Date______________
(Shutesbury: all applications. All other towns: Bedroom addition only)
Conservation Commission: ________________________________Date_______________
(When any excavation done)
Inspector of Buildings: _______________________________Date ______________ 
(After application submitted)

Explanation of work: Be specific. For example: "Install new bath and kitchen," not "Interior Renovations"

The undersigned certifies that the above statements and all accompanying information are true to the best of their knowledge and belief. The owner of this structure and the undersigned agree to conform to all applicable laws of the town and state, and believe the work proposed to be in compliance with all zoning regulations and the Massachusetts State Building Code 780CMR. SECTION 110.5 OF THE MASS. BLDG. CODE REQUIRES EVERY APPLICATION TO BE SIGNED BY THE OWNER OF THE PROPERTY, OR, BY AN AUTHORIZED AGENT. IF IT IS SIGNED BY AN AGENT, A CONTRACT SIGNED BY THE OWNER, OR LETTER OF AUTHORIZATION, MUST ACCOMPANY THE APPLICATION.
_______________________________________ _________________________________________ Date__________
(Print Name of Owner or Authorized Agent) (Signature of Owner or Authorized Agent)

NOTE: CONTRACTOR AFFIDAVIT OR HOMEOWNERS LICENSE EXEMPTION MUST ALSO BE SIGNED ON PAGE 2

Any demolition debris? No Yes Demolition Debris Disposal Location
Will a contractor be responsible for this project ? Check contractor license

Yes (Contractor must fill out Contractor Affidavit and Workman Compensation Affidavit)

No (Skip contractor affidavit and fill out Homeowner's exemption at bottom of page 2)

Contractor Affidavit: Name CSL # Hic #

Pursuant to MGL C. 142A, Home Improvement Contractor Registration, I hereby apply for a permit as the Agent of the aforementioned owner:

Signed under penalties of perjury: Contractor_____________________________Date______________________

Homeowner's License Exemption

(This portion is to be completed by homeowner assuming responsibility for proposed project. Fill this section out only if there is not a contractor taking responsibility for the job.)

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." (Section 108.3.5) The LICENSE EXEMPTION for a HOMEOWNER applies only for permitted work on owner-occupied one- and two-family dwellings/accessory structures, and farm structures. The exemption allows such homeowner to obtain building permits, perform construction, and engage individuals for hire who may not be registered or possess a construction supervisor's license, PROVIDED THAT THE OWNER ACTS AS SUPERVISOR; the homeowner is then FULLY RESPONSIBLE FOR THE PROJECT AND COMPLIANCE WITH STATE BLDG. CODE AND ALL APPLICABLE LAWS AND REGULATIONS. Many homeowners who use the "Homeowner's Exemption" are unaware that they are assuming the responsibilities of a supervisor. This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons; in these cases, punitive action cannot be taken against the unlicensed person. The homeowner, acting as supervisor, is ultimately responsible for the project and compliance with the State Bldg. Code. NOTICE TO HOMEOWNERS ENGAGING OTHERS FOR HIRE: MGL c.142A is a consumer protection law which requires Home Improvement Contractors to be registered with the State. A "Guaranty Fund" has been set up with funds collected from the registered H.I. Contractors which will be available to consumers who are aggrieved with a contract entered into with REGISTERED H.I. CONTRACTORS. This law requires that the reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition, to any owner-occupied building (containing up to four dwelling units), and to any related accessory structures, be done by registered Home Improvement Contractors, with certain exceptions.
NOTICE IS HEREBY GIVEN THAT OWNERS PULLING THEIR OWN PERMIT ON BEHALF OF A CONTRACTOR, OR WHO ENGAGE UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK, DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. Notwithstanding the above notice, I hereby apply for a permit as the HOMEOWNER of the below listed property and by so doing will assume responsibility for compliance with all applicable codes, bylaws, rules and regulations.

HOMEOWNER'S SIGNATURE : _____________________________________ DATE___________________________

SITE ADDRESS _________________________________________________________________________________

Section 2 Roofing, Siding, Replacement Windows(Place x in approriate boxes)

Roofing Any sheathing to be installed? n/a yes no Will roofing be stripped? n/a yes no

How many layers exist now n/a 1 2 3

Siding: Explain:

Repl. Windows: Number U value (Maximum U value .44)

Section 3 Signs(Place x in approriate boxes)

Size Wording

Off-premise sign(fill out Section 5 plot plan) Site location
On-premise, attached to building On-premise, free standing(fill out Section 5 plot plan)

Section 4:(Choose all that apply) Note: Any new structure or addition requires a plot plan(See Section 5)

None Storage Building( >120sft Garage Accessory Structure Addition to accessory structure Addition to dwelling Agricultural Barn Renovation to dwelling Renovation to accessory structure Chimney/fireplace Demolition Change of Use Other Size: None Storage Building( >120sft Garage Accessory Structure Addition to accessory structure Addition to dwelling Agricultural Barn Renovation to dwelling Renovation to accessory structure Chimney/fireplace Demolition Change of Use Other Size:

None Storage Building( >120sft Garage Accessory Structure Addition to accessory structure Addition to dwelling Agricultural Barn Renovation to dwelling Renovation to accessory structure Chimney/fireplace Demolition Change of Use Other Size: None Storage Building( >120sft Garage Accessory Structure Addition to accessory structure Addition to dwelling Agricultural Barn Renovation to dwelling Renovation to accessory structure Chimney/fireplace Demolition Change of Use Other Size:

Describe "Change of Use," Demolition or Other)

Provide 2 sets of plans showing:
1) Floor plan 2) Foundation plan or pier location 3) Cross section showing any of the following (if applicable): Carrying beams, floor joists, bearing walls, ceiling joists, rafters and collar ties. 4) Smoke detector locations

Fill out the following specifications appropriate to work being performed:
Foundation: Footing Size: Depth Below Grade Drainage Type

Foundation Type Thickness Height

Ht. of unbalanced fill (from grade to slab): Found. Coating

Framing: Lumber Grade and Specie(if other than #2 spruce/pine/fir)

Carrying Beam Type Size Column type Size Column span

1st Fl.Joist O/C N/A 12" 16" 24" Span 2nd Fl. Joist N/A 12" 16" 24" O/C N/A 12" 16" 24" Span

Ceiling Joist O/C N/A 12" 16" 24" Span Studding Bearing O/C N/A 12" 16" 24" Wall Height

Rafters O/C N/A 12" 16" 24" Horizontal Span Roof Pitch Collar tie size

IF TRUSSES ARE TO BE USED, YOU MUST SUBMIT TRUSS DESIGN, STAMPED BY A MASSACHUSETTS LICENSED ENGINEER, PRIOR TO FRAMING

Sheathing: Floors Walls Roof Roofing Attic/Roof Ventilation Type

Insulation: If there is a heated addition, complete the following insulation values:
Windows/Doors(.39 U Value max) Ceiling(R-37 min)*
Wall(R-13 min) Floor over un-conditioned space(R-19 min)
Basement wall(R-10 min) Slab per(R-10 min) Depth below grade(4ft min)

*R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value ovetr the entire ceiling area(i.e. not compressed.)

Bedroom escape window size:(if applicable) (Minimum 20x24 clear opening)

Section 5: Plot Plan: Provide an informal plot plan in the square below-locating the existing, new structures/additions and distances from all property lines. How far will the structure be from:

Front Lot Line Left Property Line Right Property Line Wetland/Stream/River

Frontage Lot Area Check zoning