35 CABOT ST - BPA-16-172 SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-O 6'2
T�j""t D �W1Y� r t l/1�?7 License Number Expiration Date
Name of/CSL Holder List CSL'rype(see below)
.5 y t,�C e�4kl 57 Type. Description ..
Na.:md Street U Unrestricted Ouildin a -to 35,OW cu. 11.
L,yeyz /w��-^ (J' ��U R ResUicted U2 F:unil Dwellin
Cityffo%An,State,ZIP M Masonry
RC Rooling Covering
1VS 1Vindow and Sidinst SF - Solid Fuel Burning Appliances
1 Insulation
Telephone Email address I D Demolition
.2 Registered Home Ira movement /Coontractor(HIC) �? O�� Yfi��lC
c /d OJOdo 7-e v"L[�'�r, t //1 7 5 _ HIC RegisUation Number Expiration Date
Cr 1IIC Company Name or HIC Registmnl Nnme
No:and Street Email address
bz
Ci own State ZIP Telephone
r�s•.7 U SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.I Lf 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...........O
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED.WHEN..
OWNER'S AGENT OR CONTRACTOR APPLIES 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) Date
SECTION 7b:OWNERt 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 npplication is true and accurate to the best of my knowledge and understanding.
Print or AuthonzcJ Agent's Nance(Electronic Signature) Date
NOTES:
1. 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(If IQ Program);will nu have access to the arbitration
program or guaranty fund under MLG.L.c. I'12A.Other important information onthe HICl'rogram can a oun 3t
www mass.eov;'oca information on the Construction Supervisor License can be_found at AW W.mass�
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. ft.) N (including garage, finished basement/attics,decks or porch)
Gross living area(sq. tt.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rypeof cooling system Enclosed Open
3. •Total Project Square Footage"may be substituted I'or"'rural Project Cost"