167 FORT AVE - BUILDING INSPECTION (004) ` SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number - Expiration Irate
Name of CSL-Ifolder - List CSL Type(see below)
Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Signature " M Nlasonry,Only
RC Residential Routin Covering
Telephone - WS- Residential Window and Siding
- SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
it Company Name or tI1C Registrant Name
Registration Number
Address - Expiration Date
Signature - Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.1 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 ..........O No...........O
SECTION 7atOWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
eX1'1 1 of LOv�-)S as Owner of the subject property hereby
authorize fir( (r l� �� �� r 0� to as on my behalf,in all matters
relative to work authorized by this building permit application.
1D�22I I�
—ignatureofOwner Date -
SECTION 7bt-OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are we and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent(Signed under the paim and:penalties of
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(HIC)Program),will ag have access to the arbitration.
program or guaranty fund underM,O.L.c.1S2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basemendattics,decks or porch)
Gross living.area(Sq.Ft.) Habitable room 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"maybe substituted for"Total Project Cost"