44 BRITTANIA CIR - BUILDING INSPECTION SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner ,
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Name Print) No.and Street City/Town Zip
Pi perty Owner Contact
//Information:
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Title 7 Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
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Na(7e Street Addressity/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building ermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if budding is less than 35,000 cu.ft.of enclosed space and/or not wider Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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Name(Re istrant) Telephone No. e-mail address ,y 'tgis tration Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Company Name
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Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
97Sa,?3 -7 6 -�77'`/ 69G o to h e
Telephone No. business Telephone No, (cell) e-mait a dress
SECTION 11:4Vi�RKER3'(-'OMPENSATION INSURANCE AFFIDAVIT M.G.L,c.152.§ 25C(6))
A bVorkers' Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
"I. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municinal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to 10 1 f
6.Total Cost $ j Q OG n (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Byenterirl ry i:yrne below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
applies 's a y st of my knowledge and understanding.
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VV,se print an sign name ez Title Telephone No. Date
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Street Address City/TownState Zip
Municipal Inspector to fill out this section upon application approval:
Name Date