HomeMy WebLinkAbout5015 105 Standish Way Agent AuthorizationSECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
Name of CSL Holder License Number
Expirah no Da ee
No. and Street List CSL Type (see below)
Type Description
City/Town, State, ZIP U Unrestricted (Buildings up to 35,000 cu. ft.
R Restricted 1 u2 Family Dwelling
M Masonry
RC Roofino Coverin
WS Window and Sidino
SF Solid Fuel Burning Appliances
Telephone I Insulation
Email address
5.2 Registered Home Improvement Contractor (HIC) D I Demotition
HIC Company Name or HIC Registrant Name HIC Registration Number Expirata noDa e
No, and Street
City/Town, State, ZIP
TEmail address
elephone
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 ..........
SECTION 7a: OWNER AUTHORIZATION TO BE COINIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNTIT
I, as Owner of the subject
S 4
t t on my ; in all matters relative to w k authorize s permit application.
rint own -s
�. Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perj-ury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner`s or Authorized Agent's Name (Electronic Sib ature) 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 (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.eov/oea Information on the Construction Supervisor License can be found at www.mass Qov/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 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" may be substituted for "Total Project Cost"