22 BELLEAU RD - BPA-2009-333 ROOF SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) 69 4.7&3 �1 4- ( b
�s k2 License Nuinher FNpiration Date
Nano of CSL- IIuIJer ) (, List CSL Type(see helow)
S,T T pc Descri twn
>J rrss Q L' Unrestricted to to 35.000 Cu. Ft.i
Restricted I&' F-m ly Dls ellin
Si nawrc cc J V1 NI awn Onl
l 3 ` Q�3 y RC Residential Roulin Coscrul
Telephone \YS ResiJcnual WulJue .inJ SiJm
SF Residential Solid Fuel Binning .\l III.1m: hni,J laium
D Residential Demuhtion
5.1 Registered AY
ome Improve n[ Contractor(HIC) j /v
HIC umpany Nmne ur HIC Regisir,�i Name Regutrauon Numhcr
MAt J i a QbesoV ftfA D1!360 �- �3� tc)
AJJr
1 Q q7a S��Ci 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 .......... 0 No ........... ❑
SECTION 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Signature of Owner Date
SECTION 7b::sOWNERt OR AUTHORIZED AGENT DECLARATION
1. L C (� n.-v t , as Owner Authorized Agent ereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner o thorned A ent Date
(Signed under the 2ains and penalties of r'u )
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregister:contractor(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbiprogram or guaranty fund underM.G.L. c. 142A. Other important information on the HIC Program anConstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5, ively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished busemem/attics. decks or porch)
Gross living area (Sq. Ft.) Habitable room count I
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths j
"Type of heating system Number of decks/ porches
Type of cowling system Enclosed Open j
3. 'Total Project Square Rootage" may be substituted for "Total Project Cost- '
iL