7 CIRCLE HILL RD - BUILDING PERMIT APP (002) SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 4 � 2$
-!CLYels 51nPFa't"/LQyI License slumber ia umber Exption b.te
Name of CSL Holder S l.�.1--,,,r.^e&
Il �CUtn r List CSL Type(see below) U
No.and Street p I r .I.ype Description
Sa_ut (cs 1vF{� Q)!] ID 1 U Unreslricted(Buildings u to 35,000 cu,ft.)
_l W R Restricted 1&2 fanril Dwellin
City/Tmvn,S %IP M Mason
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
si3 YI/IC( _jGt! VIVtV�pr� 1 nsulation
Tele hone Email address W1 D Demolition
5.2 Registered Home Improvement Contractor(HIC)
\11V1n± SolaEDeve Q 2Y. ��C-_ �j
HIC Registration Number E pint on ate
HIC C n any Name or HIC R gistrant Name
t F�13 P t 0D %J . Yv�aSo lGu @ V I V IYAA-soO ar.
No.and Street Email address C�rvl
Novo UT $l�kloo4 -7813o53otQs
City/Town,State,ZIP Tele 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..........lid, No _.........❑
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 VIV I II-tt SD IGLr
to act on my behalf,in all matters relative to work authorized by this building permit application.
zpY� 1 1" 10/1 /14
Print Owner's Name(Electronic Signature) I 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 Wontit' It is true and accurate to the best of my knowledge and understanding.
V - -
Print Osvt Agent's Name(Flectronic Signature) Date
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 not 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.rnass.pov/dPs
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq,ft.) Habitable mom count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'Type of heating system Number of decks/porches
'Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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V MA LICENSE:MAHIC 170848 s V CiSalemrcle Hill Rd
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