Loading...
15 BELLEAU RD - BPA-14-86 2ND STORY ADDITION SrC'CION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (SL) VPIS — License Numbur Grplr,tint . \ S Ni CO2 A \\ Nm ae our CSI. I t )AA List CSL'Type(see below) \ (,�{JA 1 Type Description \\ Nu. and�L7 • ^& A)G tJ Unrestricted EuiWin s u to 111K cu. R. ,V(r /lp/►1/v�u,� R Restricted 13c?Famil Dwollin �.3`. Ctyrrown,State,ZIP I Masonr r - RC Roofing Covering kvS Window and Will! SF Solid Fuel naming Appliances I Insulation Nle hunt Email nddrcss D Demolition 5.2 Registered Home Improvement Contractor(kI[C) /OY !M $ �g H[C RegistrationNunber Expiration Date I IIC Company Name or IIIC Registrant Narne Email address No.and Street hone City/Town,State, ZIP Tale SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 .........X No..........•13 SECTION :i OWNER AUTHORIZATIONTOBECOMPLETEDWHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT J � /yj CAS A I, as Owner of the subject property,hereby authorize 11 ! to act on my behalf, in all matters relative to work authorized by this building permit application. ¢¢,, � - Date PrZ�a fi/(Electronic Stgnaturc) 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 , lication is true and accurate to the best of my knowledge and understanding. (, ir/oi1 �DTI� c �✓! CC�Si1 Date jilt Avat's N Na me(Elzetronie Signature) NOTES: 1. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program),will nor have access to the arbitration program or guaranty find under M.O.L.c. 142A. Other important information on the HIC Program can be found at wtvw m:ua.aov%ura Information on the Construction Supervisor License can be found at wwtv.mass.rtyn_,II_ ;. When subst:mtiai work is planned,provide the information below: _(including garage, finished bascrncnttattics,decks or porch) Total floor area (i ft.) ----- Ifabitnble room count Number of tirrphuce _ tins; Irving area — Number of bedrooms uus_It)-------- Number of halBbaths -__ ----�_ Number of bathrooms __------ --- I cpo of ha;uing sy;tcnt — .--- Fncloscd pen I\pe of eo,lirn� ;y;tcnt :. ol.d 1'1010�:t ❑t.ty he alh;tiuit:d too [''t.11 I'ngccl 71a 1 1 a7 � I I y I I i I � I I �j t aW)s m) n va 7R9s r tv V7 �-29 657.E- _L k -V lu a-n�1S -f ! a � L/A\\ VII v. . 6-01 --�� Lw 0 i y glco 1 -7 LJ © Rom' O 3 C Co5ty cfl S B-f.LL-e A U (ZtJ F I r=LAT Roo►_ ov tlSI x a 71 ® , - t - (11Of_ n�� �� s T..____..�.n._.�__ __ ---_-_�.�.______ ��._._� _ ---- - _1— f __ i i -- V ill i I C®E)P A OZLD& e, U ems` --- 3o yr Rjj , AZ(-AITCCTukA(- 54P,GLes ` ozooyRY 9 CID jvew ),X D CeILIN4 aX C 51-y D Ila chi( s&A- wc,- - ly-ew k "ucluxc St ) e a S e C 1 cc) p U r CLZ-) Fx ►s-t,N S f RoOR