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70 BRIDGE STREET - BUILDING JACKET jo up►crob, 111 I BMCADr KEEPING YOU ORGANIZED NIo. 1O3Q1 Raw AMSIUSA c�toRaN®aee�coa The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM ElBuilding Massachusetts State Building Code, 780 CMR RevisedShin 201Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Fanrly Dwelling This Section for Official Use Only ' Building Permit Numbers Date:Applied: . Building Official(Print Name). SignatureDate SECTION 1:SITE INFORMATION` LiPrope{�A dress: L2 Assessor Map&Parcel Number L la Is this an accepted strect9yes___X no Map Number Parcel Numbcr 1.3 Zoning Information: IA Property Dimensions: c Zuning District Proposed Use Lot Area(sq It) Frontage(it) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required - Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Munici On site disposal system ❑ Public Private❑ -Check if es❑ p°l' po Y SECTIONZ: PROPERTYOWNERSHTP!`` 2.1 Ow ert of Record: r t N&`Jlk �✓lnnky.lvo k, 6197 N"e(Print City,State,ZIP 70 d y, SF 6117-75540 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply_) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s)JX Alteration(s) ❑ Addition 49' Demolition ❑ Accessory Bldg.E3 Number of Units_ I Other ❑ Specify: Brief Description of proposed Work': eco 7o.wr oe, 41,,daor e.4/ 'r- n ,r SECTION 4: ESTIMATED CONSTRUCTION COSTS Item (Labor Costs: Official Use Only Labor and Materials) - I. Building 5 LIZ, bo$ oa 1. Building Permit Feer$ Indicate how fee is determined: S 2 I ❑Standard City/Town Application Fee 2. Electrical DT0,00 ❑Total Project Cosh(Item 6)x multiplier s 3. Plumbing S i 'i 2O�!..00 2`?Qther Fees: 3 4.�IcctianicaI (HVAC) .S List: " 5,Mechanical (Fire S Suppression) All - � Check No. Check Amount: Cash Amount:_ G.Total Project Cusk .S ) S,l1a ❑Paid in Full ❑Outs Balance Due: IU 2 SECTIONS: CONSTRUCr1UN SERVICES 5.1 Construction Supervisor License(CSL) _ CS^I0 0 t,7 h � zo f y License Number Expiration Date s N:une of CSL Huller (/J (� List CSL'fype(see below) _ G �" d No.and Street Type' .. : - Description . U - Unrestricted Buitdin u to 35,000 cu. It. WrITt-AG ft/ 61 I R I Restricted 1&2 Family Dwelling City/1'uhm,State,ZIP ht Mas RC -Roofin Coverin WS -1Vindow am!Sidin SF Solid Fuel Burning Appliances 3�j(per 23S—A qS— I Insulation Telephone. Email address D Demolition 5.2 Registered Homp Improvement Contractor(HIC) --7 $ /"I"'u UTC Registration Number Expiration Date HIC Com :my Name or HIC eggistranl Name Z00d LitM✓h5 'h /MLt��yt+ctl.ln No.and StreetLL Email address ,Qtt< /V U D3*5 Ci /Town State ZIP Tel hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.1511 2SC(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..........0- 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 tg act on my behalf,in all matters relative to work authorized by this building permit application. Print Osmer's Name(Electronic Signature) Date SECTION 7b:OWNERI 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 ap li '0 true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Nu ne(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program);will nut have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at www.mass:eov'oca Information on the Construction Supervisor License can be.reund at www.nhass.rov!das . 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. R.) - - _ Habitable room count Number of fireplaces - Numberof bedrooms r Numberofbathrooms Number of half/baths Type of heating system Number of decks/porches Type ofcooling system Enclosed Open J. "Total Project Square Footage"may be substituted for"Total Project Cost" a� The Commonwealth of Massachusetts -- — ;,' Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM ? Revised.tlai 2011 Building Permit Application To Construct, Repair. Renovate Or D sh a Our- or Two-Family Do eltu q This Section For ic'al Use Orfl Building Permit Number: ate Applied Building Official(Print N;une) Signa ure U tc SECTION 1:SITE INFO i�Property J` 1.2 Assessors Ma arcel Numbers I.1a Is this an ace pted street?yes _ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: y Zoning District Proposed Use Lot Area(sq Ilt Frontage(11) 1.5 Building Setbacks(B) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if—s❑ Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Ownert of Record: go 5 ,U4v N;une(Print) City.State,ZIP Fi ec-// :T/,xv e No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building O Owner-Occupied ❑ 1 Repairs(s) Alterations) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Propose�W1.o�rk': 9�- Q re- SECTION a: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only ILaher and .Materials) Y I. Building g / Q� a0 I. Building Permit Fee: S Indicate how fee is determined: '. tilectrical g �O aQ ❑Standard City,town Application Fee ❑Total Project Cost (Item 6)x multiplier x i. Plumbing S 1 P — — _. Other Fees: S 4. \lechanical (11\',\C) S List:__ � \Icchanical IFirc 'I ucssionl S Total All Fees:S_ b. Total Project Cost: S 6p Check No. _Check Amount: __--- Cash:\mount_ o? DOG ❑Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) X -4 .. Licensor Nunther Pspiration Date Name of CSL I lulder ,C,/� ' Lisl CS I,I)pe(see below) Tc Description No. and titreel /� . ,/ p I l lnrestncicd(Buildings ti to)5,11110 Co. Il.l /NGYSS � /D.2_ Restricted L@2 Famil Docllin Citeffo++n.Slate.ZIP ��- Nlasonry RC Rooling Covering W'S Window and Siding SF Solid Fuel Buming Appliances e:W ,5W 4y�/e� I Insulation 'I'cle hone w I g,,-1 address D Demolition 5.2 Registered IlumQe Improvement Contractor(HIC) /S-//0 aD/ IIIC Registration Ntunher lispi- tam Dale I IIC Company�N unc or I IIC Registrant Name , =?D�/ fY /7J�JI7c J Do,-yel h7 &Jq�JLJ 1 C (10�Y1• ��f� Nu. ;tad Street / Email addmss�� Ci /Town,State,ZIP "rele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 Las Owner of the subject property, hereby authorize J)Onl :� Am^l U L/ to act on my behal n all matters relativ o work authorized by this building permit application. :%6 'rint Owner's Name(ElectmnicSignature) —ate 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 contai d in this application is true and accu a to a best of my knowledge and understanding. - ' ' +n� '' nrci zcJ agents me(Electronic Signature) Dale 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 Hume Improvement Contractor(HIC) Program),will trot 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 in.t Information on the Construction Supervisor License can be found at k.%AN.y m;ts,. Jp, 2. When substantial work is planned, provide the information below: Total floor area(sq. ft.) (including garage, finished basement'attics,decks or porch 1 Gross li%ing area(sy. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half haths 1. peofheatings)Ste111 -- _ - - ___-- _- - Number ol'decks, porches__- ---_-- - 1)pc of cooling Suter➢ -. _ Enclosed __ Opelt i, "Tonal Project Square rootage-may be Suhstituted ftr''folal Project Cost' a ti iN� �o � �'/USA 1 r i ��s//LJJ✓,��� tUlly..sf�/� �L=suelacr A1044, r �aGwu h - .a • /lam i UL - c�LEC t E/rC C� I C K 53c5 The Commonwealth ofblassachusetisSPECT ION AL SER ICE�ITYOF Board of Building Regulations and Standards SALENI WMassachusetts State Building Code, Aso CNN FEB -3 A )Q,%ed Slur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Cr— Building Permit Number: Date Ap lieds building Otticiul(Print Name). Stbn�� I SECTION I:SITE INFOR�HATION.' L1 Proper Add r ss: 1.2 Assessors Mop dt Parcel Numbers 70 tr.7� ! 1.1a Is this an accepted street9 yes no Map Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sy lt) Frontage(Il) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard 7Water Provided Required Provided Required Provided ply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Municipal On site disposal system ❑rivate O — Check if es❑SECTION2. PROPERTYOWNERSHW. 0 R cord: ;? d t �t..+ y 019-7D /V G..I IMOV�� V-�Vo o �hme(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s)Af I Addition ❑ pBrit:f ion ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: scription of Proposed 1Vork'; a,, t- C W,p.,d �$ a5rc A w non^ on w tSECTION 4: ESTIMATED CONSTRUCTION COSTS Itm Estimated Costs: Official Use Only Labor and Materials) - I. Building $ 2q y so r va 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ 30 S Oe,CD ❑Total Project Cost?(Item 6)x multiplier x 3. Plumbing $ )51000.00 2�9ther Fees: .$ 4.Nlecltmtical (FIVAC) $ List: 5. Mechanical (Fire Y Total All Fees:S Su ression) 2 q S0� Check No. Check Amount: Cash Amount: 6.Total Project Cost: s I ❑Paid in Full ❑Outstanding Balance Due: 6'r�"LL -Fo Z I I o c r?1 p}`/;('??J, {j{„ SECTION5: CONSTRUCTION SERVICES 5.1 Constructimt Supervisor License(CSL) &,.,4 S IMU",�,f- - �I ,f i � License Number E!epirution Date N;miic of CSL Holder I �,71P List CSL'Type(see below) Cs _ OO Typo Description No. and Street ��,`M ar L` U Unrestricted Buildin s u g to 35,000 cu. It. Rd 1 R Restricted I&2 F:unil Dwellin Cityfrown,Stale,ZIP M Masonry RC Roolinji Covering WS Window and Sidin ''Y,, SF Solid Fuel Burning Appliances Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) kw /''v,'5-e 1-7 g ZZ Y HIC Registration Number Expiration Dane HI Cumpan Name or I C Registrant Name - 14; Fe pp. �d a No.and M1 ./N D-4OSy 3 -�3S_��ys- Email address Ci /Town State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.I5Z.4 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........... O SECTION 7o:OWNER AUTHORIZATION:TO BE COMPLETED WHEN.-. OWNER'S AGENT OR CONTRA&OItA0PL1ES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize t9 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 ORAUTHORIZED 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 accu best of my knowledge and understanding. �µ ��1,,,s-r 213110 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 Home Improvement Contractor(HIC) Program);will nn have access to the arbitration program or guaranty fund under M.G.LL.c. Ia2A.Oth-c important information on the HIC-Program can bie found at---- - �eww mass.eov+'oat Information on the Construction Supervisor License can be foundat www.mass.��ov%'dns . 2. When substantial work is planned,provide the information below: 'total tloor 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 ofcoolingsystem Enclosed Open 3. `Total Project Square Footage"may be substituted ror'Tutad Project Cost" a� The Commonwealth of Massachusetts -- — ;,' Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM ? Revised.tlai 2011 Building Permit Application To Construct, Repair. Renovate Or D sh a Our- or Two-Family Do eltu q This Section For ic'al Use Orfl Building Permit Number: ate Applied Building Official(Print N;une) Signa ure U tc SECTION 1:SITE INFO i�Property J` 1.2 Assessors Ma arcel Numbers I.1a Is this an ace pted street?yes _ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: y Zoning District Proposed Use Lot Area(sq Ilt Frontage(11) 1.5 Building Setbacks(B) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if—s❑ Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Ownert of Record: go 5 ,U4v N;une(Print) City.State,ZIP Fi ec-// :T/,xv e No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building O Owner-Occupied ❑ 1 Repairs(s) Alterations) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Propose�W1.o�rk': 9�- Q re- SECTION a: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only ILaher and .Materials) Y I. Building g / Q� a0 I. Building Permit Fee: S Indicate how fee is determined: '. tilectrical g �O aQ ❑Standard City,town Application Fee ❑Total Project Cost (Item 6)x multiplier x i. Plumbing S 1 P — — _. Other Fees: S 4. \lechanical (11\',\C) S List:__ � \Icchanical IFirc 'I ucssionl S Total All Fees:S_ b. Total Project Cost: S 6p Check No. _Check Amount: __--- Cash:\mount_ o? DOG ❑Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) X -4 .. Licensor Nunther Pspiration Date Name of CSL I lulder ,C,/� ' Lisl CS I,I)pe(see below) Tc Description No. and titreel /� . ,/ p I l lnrestncicd(Buildings ti to)5,11110 Co. Il.l /NGYSS � /D.2_ Restricted L@2 Famil Docllin Citeffo++n.Slate.ZIP ��- Nlasonry RC Rooling Covering W'S Window and Siding SF Solid Fuel Buming Appliances e:W ,5W 4y�/e� I Insulation 'I'cle hone w I g,,-1 address D Demolition 5.2 Registered IlumQe Improvement Contractor(HIC) /S-//0 aD/ IIIC Registration Ntunher lispi- tam Dale I IIC Company�N unc or I IIC Registrant Name , =?D�/ fY /7J�JI7c J Do,-yel h7 &Jq�JLJ 1 C (10�Y1• ��f� Nu. ;tad Street / Email addmss�� Ci /Town,State,ZIP "rele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 Las Owner of the subject property, hereby authorize J)Onl :� Am^l U L/ to act on my behal n all matters relativ o work authorized by this building permit application. :%6 'rint Owner's Name(ElectmnicSignature) —ate 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 contai d in this application is true and accu a to a best of my knowledge and understanding. - ' ' +n� '' nrci zcJ agents me(Electronic Signature) Dale 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 Hume Improvement Contractor(HIC) Program),will trot 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 in.t Information on the Construction Supervisor License can be found at k.%AN.y m;ts,. Jp, 2. When substantial work is planned, provide the information below: Total floor area(sq. ft.) (including garage, finished basement'attics,decks or porch 1 Gross li%ing area(sy. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half haths 1. peofheatings)Ste111 -- _ - - ___-- _- - Number ol'decks, porches__- ---_-- - 1)pc of cooling Suter➢ -. _ Enclosed __ Opelt i, "Tonal Project Square rootage-may be Suhstituted ftr''folal Project Cost' a ti iN� �o � �'/USA 1 r i ��s//LJJ✓,��� tUlly..sf�/� �L=suelacr A1044, r �aGwu h - .a • /lam i UL - c�LEC t E/rC C� I C K 53c5 The Commonwealth ofblassachusetisSPECT ION AL SER ICE�ITYOF Board of Building Regulations and Standards SALENI WMassachusetts State Building Code, Aso CNN FEB -3 A )Q,%ed Slur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Cr— Building Permit Number: Date Ap lieds building Otticiul(Print Name). Stbn�� I SECTION I:SITE INFOR�HATION.' L1 Proper Add r ss: 1.2 Assessors Mop dt Parcel Numbers 70 tr.7� ! 1.1a Is this an accepted street9 yes no Map Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sy lt) Frontage(Il) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard 7Water Provided Required Provided Required Provided ply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Municipal On site disposal system ❑rivate O — Check if es❑SECTION2. PROPERTYOWNERSHW. 0 R cord: ;? d t �t..+ y 019-7D /V G..I IMOV�� V-�Vo o �hme(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s)Af I Addition ❑ pBrit:f ion ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: scription of Proposed 1Vork'; a,, t- C W,p.,d �$ a5rc A w non^ on w tSECTION 4: ESTIMATED CONSTRUCTION COSTS Itm Estimated Costs: Official Use Only Labor and Materials) - I. Building $ 2q y so r va 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ 30 S Oe,CD ❑Total Project Cost?(Item 6)x multiplier x 3. Plumbing $ )51000.00 2�9ther Fees: .$ 4.Nlecltmtical (FIVAC) $ List: 5. Mechanical (Fire Y Total All Fees:S Su ression) 2 q S0� Check No. Check Amount: Cash Amount: 6.Total Project Cost: s I ❑Paid in Full ❑Outstanding Balance Due: 6'r�"LL -Fo Z I I o c r?1 p}`/;('??J, {j{„ SECTION5: CONSTRUCTION SERVICES 5.1 Constructimt Supervisor License(CSL) &,.,4 S IMU",�,f- - �I ,f i � License Number E!epirution Date N;miic of CSL Holder I �,71P List CSL'Type(see below) Cs _ OO Typo Description No. and Street ��,`M ar L` U Unrestricted Buildin s u g to 35,000 cu. It. Rd 1 R Restricted I&2 F:unil Dwellin Cityfrown,Stale,ZIP M Masonry RC Roolinji Covering WS Window and Sidin ''Y,, SF Solid Fuel Burning Appliances Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) kw /''v,'5-e 1-7 g ZZ Y HIC Registration Number Expiration Dane HI Cumpan Name or I C Registrant Name - 14; Fe pp. �d a No.and M1 ./N D-4OSy 3 -�3S_��ys- Email address Ci /Town State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.I5Z.4 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........... O SECTION 7o:OWNER AUTHORIZATION:TO BE COMPLETED WHEN.-. OWNER'S AGENT OR CONTRA&OItA0PL1ES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize t9 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 ORAUTHORIZED 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 accu best of my knowledge and understanding. �µ ��1,,,s-r 213110 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 Home Improvement Contractor(HIC) Program);will nn have access to the arbitration program or guaranty fund under M.G.LL.c. Ia2A.Oth-c important information on the HIC-Program can bie found at---- - �eww mass.eov+'oat Information on the Construction Supervisor License can be foundat www.mass.��ov%'dns . 2. When substantial work is planned,provide the information below: 'total tloor 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 ofcoolingsystem Enclosed Open 3. `Total Project Square Footage"may be substituted ror'Tutad Project Cost"