wagner permit app p2SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
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License Number Expiration Date
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List CSL Type (see below) W
Name of CSL Holder
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b 6 15;,cType
Description
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No. and Street
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U
Unrestricted (Buildings u to 35,000 cu. ft.)
R
Restricted 1 &2 Family Dwelling
City/Town, State, ZIP
M
Masonry
RC
Roofing Covering
WS
Window and Siding
SF
Solid Fuel Burning Appliances
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T
Tnsulation
Telephone Email addtless
D
Demolition
5.2 Registered Home Improvement Contractor (HIC)
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HIC Registrati n Number Expiration Date
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HIC Company Name or HIC Registrant Name
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No. and Street
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Enlail address
City/Town, State, ZIP 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 ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property, hereby authorize t'Ili t.. Aa?#If -a--
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: OWNEW 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 understanding.
L E64Ai"—,-- 2v
Print Owner's or Authorized Agent's Name (Electronic Signature) Date
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. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"