PermitPG4SECTION .& - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Name of License Holster
Not Applicable D
License Number
A-> (i
Address
�12
Expiration Date
Signa ure -�Telephone
9. Registered Home Improvement Contractor
Not Applicable
Company Name
Registration Number
Address
Telephone
Expiration Date
SECTION 10- 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
Affidavit Attached Yes....... 1W No...... ❑