7 BERUBE RD - BPA-15-308 NEW STAIRS SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
s
Name of CSL Holder '
List CSL'Type(see below)
No. ;md Street Type. ._ Description
U Unrestricted(Buildings tip-to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofina Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demoon
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
_Ci /_T_oAvn State ZIP__ _ Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§25.C(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►s§uance of the building permit.
Signed Affidavit Attached? Yes ..........a No...........❑
SECTION 7n:OWNER AUTHORIZATION,TO BE.COMPLETED,WHEN
OWNER'S AGENT OR CONTRACTOMAPPLIES FOR BUILDING.PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNEW ORAUTHORIZED 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.
/�2
a Owner'i or,Ant iorized i gcnt's Name(Electronic Signature) mate
NOTES:
I. 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 Liol have access to the arbitration
program or guaranty fund under M.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
www.mass.eov'oca Information on the Construction Supervisor License can be found at wwtv.mass. ov:'dns _
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'rype of heating system Number of decks/porches
'type of cooling system Enclosed Open
J. "I'otal Project Square Footage'may be substituted f'or"'rOUI Project Cost"