18 BROAD ST - BUILDING INSPECTION (3) SECTION 5: CONSTRUC'TION SERVICES
5.1 Construction Supervisor License(CSL)
I.icense Number Expiration Date
Nantcul'('SI. IIuIJer -------
List CSI. I)PC(sec below)
No. and Street Type Description
11 Unrestricted(Moldings uP to 35,000 cu. 11.)
-- R Restricted lK2 FamilyDwelling
Citylfown.Sluts.ZIP M Mason
ry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC' Registration Number Expiration Date
I IIC Company Name or I IIC Registrant Name
No. and Street Email address
Cityrrown, State, ZIP Tnlc hone
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
I, 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.
Print Owner's Name(Electronic Signature) Date
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 application is true and accurate to the best of my knowledge and understanding.
Print ON%ner's or Authorizcd Agent's Nance(Electronic Signature) Dale
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(aunt registered in the Home Improvement Contractor(HIC)Program),will riot have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
y%to ma ,,gyy oc.t Information on the Construction Supervisor License can be found at t��y�a nr,)ss.go� 'Ji1_
'_. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basemenCattics,decks or porch)
Gross living area(sy. It) _ _ Habitable room count _
Number of fireplaces Number of bedrooms
------------------
Number of bathrooms __ _ _ Number of half baths
l,pe of heating system _ _ --_- -- Number of decks,porches -
-
I')peofcoolingsystem _ ...__...._.___.—___.__ Enclosed Open
1. "foml Project Square Footage-ntay be substituted titr"f ulal Project Cost"