18 AMANDA WAY - BUILDING INSPECTION (2) r
SECTION 5: CONSTRUCTION SERVICES '
5.1 Construction Supervisor License(CSL) �S 099V3
License Number Ex ation ate
Name of CSL Holder
— List CSL Type(see below) _
No.and Street Type Description:
C Q 0/+'1 U Unrestricted(Buildings u to 35,000 ca.ft/�� AA,,,, .
r/ , /A!O R I Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Masonry
RC Roofin Covetin
WS Window and Sidin
q no SF Solid Fuel Burning Appliances
II Insulation
ele hone Email ress D Demoli 'on
5.2 Reg,,is red Ho a Imnprove �eyn�tj,Cy�opnt,,ractor(HIC)
0 ow tIS T67n C o e or t Name HIC Registration Number xpir urn to
C ' tran
Str t�
Email a dress
Ci /Town State,ZIP ele hone p/
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L, .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 R CONTRACTOR APPLIES FOR 13VILDING 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 ame(E1#ctrq#c 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.
UIAA0 90
Print Owner's Authori ed cm's ame(Electronic Signature) ite
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
wtivw.mass. ov,'oca Information on the Construction Supervisor License can be found at www.mass.sov/dps
2. When substantial work is ularined,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'
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18 AMANDA WAY, SALEM MA 01970