31A-333 (2) /
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 0$3(oO Z. dDate
ZiLicense Number
Name of CSL Ho er
List CSL Type(see below) U
No.and Street / Type Description
y� y�,, U Unrestricted(Buildings up to 35,000 Cu.ft.)
� "t '�'`` 't &l ) O'O� ( R Restricted 1&2 Family Dwelling
City/Town,State,Z)P1 ` M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
41303 77,6 f O Y. SV 1 Lbe I Insulation
Telephone Email address 6" 4)Lr COY' D Demolition
5.2 Registered Home Improvement Contractor(HIC) i7S(1 5 a q lug
Itv n 0 S HIC Registration Number xpira on Date
HIC Company N'Xme 'or C Re8��t Name
z� 1.lz 11. LoC
MS gl)I =61441 L.l
CA and S t 0\o rt 41,3
n 61 e Z Z/4 Email address
City/Town,S Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes No .ElSECTION 7a:OWN R AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 1t,.._ Lt rRB
to act on my behalf,in a matters relative to work authorized by this building permit application.
J /6 /.,1
Print Owner's Name ectronic Signature) Date
SECTION 7h:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understan ' g.
I1VS,\_ ,V'S
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will.not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) 34104 (including garage,finished basement/attps,decks or porch)
Gross living area(sq.ft.) 7,1 1 Habitable room count $
Number of fireplaces ( Number of bedrooms 4
Number of bathrooms "3 Number of half/baths A
Type of heating system 7 fl1 R2 _Number of decks/porches'..
Type of cooling system I l Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"