HomeMy WebLinkAboutBuilding Permits Backfile1 Section A - Workers' Compensation insurance Affidavit (M.G.L. c. 152 S 25C
Workers Compensation Insurance affidavit must be completed and submitted with this application. Faiiure
to provide this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes .......... No ..........
N
Section 5 - Description of Proposed Work (check all applicable)
New Construction ❑ Existing Bldg. ❑ I Repair(s) ❑ Alterations ❑
Addition ❑
Accessory Bldg. ❑ Type Demolition
Other Specify:
Brief Description of Proposed Work:
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Section 7a -
Owner's Agf
I,
vner Authorization - To be Completed Wt
or Contractor Applies for Building Permit
Check Below
❑ Conservation -Commission Filing
(if applicable)
❑ Old Kings Highway & Historical
Commission approval
(if applicable)
, 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.
Signature of Owner
Section 7b - Owner/Authorized Agent Declaration
Date
, as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate.
to the best of my knowledge and belief. I
Signed under the pains and penalties of perjury.
Print name
Date
7.1-99 2 of 2