35 ANDREW ST - BPA-08-973 PART. ROOF SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) O 9 y^T 63 =)y-- 10
License Number E\pnation Date
NunnBo CL- FMiulJer List CSI_Type lsee below)
"r �Z— �'P A ��aV' T c Descri ltion
1ddn+,t�� Unrestricted fill, 3i,000 Cu. Prl
R Restricted 18e'_' Fa[mnily Dwelling
Signature M Masonr,, Onl
�'� 53l 72,3c - RC Residential Rooting COVe"In,
Telepltune WS Residential Window .utd Sld1110
SF Residential Sutid Fuel 13unune :\ ilianre InseilLuinn
D Kesidential Dcmolniun
5.2 Registered lame Improven ent Contractor (HIC
Registration Number
HIG M��an ir ,C g�gislrut me
j l�o m i/ , lei
Addre _Q�yc _ �I R �^� Expiration Date
Signature .—// 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
to act on my behalf, in all matters
authorize
relative to work authorized by this building permit application. _
Date
Signature of Owner
SECTION 7b: OWNER t OR AU"PHORIZED AGENT DECLARATION
as Owner or Authorized Agen hereby declare
that the statements and information on the foregoing application are-true and accurate, to the best of my knowledge and
behalf. . n
Print Name q'—
= e ._ r
Signature of Owner o Authonzed A ent F Date
(Signed under the pains and enalties of perjury) NOTES:
1. An Owner who obtains a building permit to do his/her own work,ur un owner who hires an unregistered contractor
(not registered in[he 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 and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations t 10.R6 and 110.R5. respectively.
2 When substantial work is planned, provide the information below:
Total Floors area(Sq. Ft.) (including garage, finished basemenUuttics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of decks/ porches
"type of heating system Number of decks
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted fir "Total Project Cost'