31C-081-006 �G ( C"f'15 >'/ nJ , (,U 7 Le
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SECTION 5: CONSTRUCTION SERVICES 3 v
5.1 Co true 'on Supervisor License(CSL) e_i "fc o /. C 1
sp,J� ��r- Licensee Number `f J Date f `�J�/
Name of CSL Hot er )
gi/ (�List CSL Type(see below)itiel Type Description
No. Stir _
M �$T Vf(1U7 U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,LIP Ail
V V 1R Restricted Masonry
1&2 Family Dwelling
asonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 'stered Ho Irpprovepn t Contractor(HIC) /�30
Wfwoo c..wI cr6' HIC Registration umber E ua on Date
HIC por HIC Rggistrant Name / / L
.ryu eJ calm &coMCaSt lie}
�Io. StEeheed, O/OO/ ��11/oo 3 Email address
City/Town,State,LIP Telephone (J
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 Issuan of the building permit.
Signed Affidavit Attached? Yes No .❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: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
c_ontaaiin in this application is true and accurate to the best of my knowledge and understanding.
ai
5rr O
Print Owner's or Autho zed Agent's Name(Electronic Signature)
!! NOTES:
1. 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.ikalifiwa substantial Work is planned,provide the information below: ,,,
Total door area(sq.ft.) a`\o� (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.*. .3\' 't Habitable room count '�
Number of fireplaces Number of bedrooms
Number of bathrooms r\ Number of half/baths
Type of heating system "I, Number of decks/porches .\
Type of cooling system '3 Enclosed ~ Open \
3. "Total Project Square Footage"may be substituted for`Total Project Cost"
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