24D-329 203 King St kfc reno contractor page Version l.7 Commercial Building Permit May 15.2000
SECTION 10•STRUCTURAL PEER REVIEW(780 CMR 110.111
Inde neem Sbudurel E StrucWral Peer Review Required Yen No _
SECTION 11.OVVIER 710N-TO BE CONI L YED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, _ �✓/fn'e .� as Owner of the subject DropeM
here /by authorize ` /,s to
adzIn an measfs+glabn to wmk auMorized by mk building permit eppinsabon.
titu .nt �_- _- R Dr
Eric Renegar an OseverlAuthonzed
Agent hereby declare that Me statements and Information or,the imagining application era true and accurate,te Ore best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
'Eric M. Renegar
vdm Naga, �—
r a/as-iall is
Slpn tursof Owner/Agent Data
SECTION 12-CONSTRUCTION SERVICES
10.1 Llcenaed Cornbuellon Sumeryii Not Applicable 0
Name of Llcome NUMm L Gb4j6rR&noly MPAM/C5
UExus Number
Address ENNreeon Date
Signature Telephsre
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152,125C(SR
Workers Compensation Insurance allidirm must be completed ann submitted With this application.Failure to previee this affidavit will res At
in Me dan1N ssu
o/the iance of the building permit
Si ned AffitlaWt Ahached Yea No O
JJo�FS® �c5ie�r�4r�s _ �£r