4 ATLANTIC ST - BPA-09-177 REMOVE/REBUILD DECK SECTION 5: CONSTR( CHON SERVICES
5.1 l.icensed ('oiistructioitStaper%i.sor (C'Si )
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5.2 Registered Ilonne Improscrinent Cuntractor (111C)
illipajiN \�,jnc m HIC Rc�i,tiaiit Name R"i, uoii md,c�
SECTION6: WORKERS' CO.NIPENSATION INSURANCE .%FFID,Al,[T1NI.C.L. c. 152. § 2506))
Workers Compensation Insurance atticlavit must be c,-r-ripleied and uhromed with this Appllcat'-M F.H11J1Cti- j)111111e
this atticlavit will result in the denial of the Issuance tit the building permit.
Signed Affidavit Attached? Yes ..... -- 0 No , 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. as Owner of the ,,hj,:,i property hereby
P
jolibia ize hIllclit, in all MAICIN
to ,wrkauthorized by this building permit application.
swlllwle 11-1 Owner Date
SECTION 711b: OWNER' OR .%uTtiORI ZEDA GENT DECLARATION
I. --. as Owner orAuthorized \-entheichydeclare
that the state ments and in tormationon the loregoini: application are true and accurate, to the best of mi, know icd L!e and
behalf,
Print Name
Date
Signed under the pain,and penalties of perjuryj
NOTES:
I. An Owner who obtains a building permit it, do his/her own Mork. or ano\%ner who hires 111
(no( registered in the Florne lmpr,).einent Contractor ffilC) Program), will nw ha%cocceN, io iheathitiall"n
program or guaranty tund under M.Ci L c 142.A Other important inh Pi mationon the I IIC Program and
Consti uctli in Supervisor Licensing WSI-)can be found in -80(.AIR Regulation, I II).RO And I 10 R 5. f c,pect I CIN
When uhsiamiai work is planned. pioNide the inlopmation below
Total flo,irs area 1 Sq. Ft.P i inchichns! garage. toii,hed ha,einciiUmn,s, decks ,,r poi,h I
(inns 11 t ing" area I Sq. Ft.) Habitable room count
Nuivilberct nielplaces-- Number of hedn,- oll
Nuinhcr of h,d;
I we it heannv 1%,iern Nmnhei 14 11CLk" 11'1-he,
,,,ding %,acm
Pr,'JCLI Square nlaly be UMtituted h,r 5,t.d Project C'.,t
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