20 SABLE RD - BUILDING INSPECTION (3) SECTION 5: CONSTRUCTION SERVICES
5.1 Construe tioh'tSi ervisor License(CSL)
m�,nxa,ter: ITI"gal4l 90 39 3 .3— ) — 1S
V4US Ft N eJ M E1,0 License Number E,cpi ration Date
N:une of CSL Holder
I� w k_ F xi List CSL Type(see below)
]e �i61L, Gr2
No.and Street d Type Description
��d��� <? U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted I&2 Family Dwelling
CityfFown,State,ZIP - M Mason
ry
RC Roofing Covering
WS Windowand Siding
r SF' Solid Fuel Burning Appliances
�f U J/N V0041, Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(111C) I.DO 9S3
� i41 L�
1� EBB S Cf tC r ZJer/J/ C _ HIC Registration Numlx:r Expiration Date
I-Ile Compan Name or HIC Registrant Name
_ nQa' tN�S G'f Z— �SN. _a)"
No.; d.tree! 1Yl✓S7mr�OM ElO
"19 01V,60 g�A`e�>�x// Email address
City/Town,S e,ZIP Telel�hon--e—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 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
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 tinder 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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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 Flonme Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. 1 d2A. Other important information on the HIC Program can be found at
www.ntass.eov/oc:t Information on the Construction Supervisor License can be found at www.niass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. fl.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R) Habitable room count_
Number of fireplaces _ Nummber of bedrooms
Number ofbathroonns Number ofhalf/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'