31C-081-015 7 (IçIiiJ Wxy -44 (S
SECTION 5: CONSTRUCTION SERVICES 3 1 "*()
YI
5.1 Co true 'on Supervisor License(CSL) /re_O i n
67 o,ci ..rr License Number( ff CJ ti Date 015
Name of CSL Holier )
Si/ - List CSL Type(see below) (�
�' a 4kied 1�hiliG/ Type Description
No. Strf et
Lis/ Al )V U Unrestricted(Buildings up to 35,000 Cu.ft.)
l/ / /'(ff R Restricted 1&2 Family Dwelling
City/Town,State,ZDP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 gistered Ho prove �n t Contractor(MC) /a •�O
L. woo v.11ers HIC Registration Number E rra on Date 1HIC p e or HIC R strant Name / / L
.Orel jJ 50,01r d &GorekasSt oc
�Io S e s ,// O/0004 1/5 9-i000 Email address i
City/Town,State,,'LIP 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 Iss of the building permit.
Signed Affidavit Attached? Yes No 0
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
contain in this application is true and accurate to the best of my knowledge and understanding.
\1 Otc!f17' 0
Print Owner's or 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 fluid 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. pan substantial work�is�planned,provide the information below:
Tota oor area(sq.ft.)�'cMt (including garage,finished basement(atttics,decks or porch)
Gross living area(sq.ft'A\tic) Habitable room count "s
Number of fireplaces Number of bedrooms "5
Number of bathrooms 3 Number of half/baths
Type of heating system 3 Number of decks/porches 1
Type of cooling system Enclosed — Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"