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SECTION 4-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L t 152§25C(6)) <br /> Workers'Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will <br /> result in the denial of the issuance of the building permit <br /> • Signed Affidavit Attached: Yes❑ No❑ <br /> SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) <br /> New Construction ❑ Existing Building Cl Repair(s) ❑ Alteration(s) ❑ Addition <br /> Accessory Bldg. ❑ Demolition ❑ ❑ <br /> Other O Specify; 1` `G.�, <br /> Brief Description of Proposed Work: <br /> Structure Overall Dimension: Length - t Width / <br /> • Height <br /> SECTION 6-ESTIMATED VALUE OF CONSTRUCTION <br /> Item_ Estimated Value to be <br /> c mpleted by permit applicant Official Use Only <br /> 1.Building <br /> (a)Building Permit Fee Multiplier <br /> 2.Electrical (b)Estimated Total Cost of <br /> 3.Plumbing Construction from 6 <br /> 4.Mechanical(HVAC) Building Permit Fee <br /> 5.Fire Protection (a)x(b) <br /> 6.Total=(I+2+344+51 Check Number <br /> • SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN <br /> OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT <br /> <x/ as Owner of the subject property <br /> / \ hereby authorize <br /> my behalf,in all matters relative to work authorize by is building 't ap tc don. to act on <br /> / Dm <br /> SIgNNR O(ON'IIR f D <br /> i <br /> SECTION 7b-O R/AUTHORIZED AGENT DECLARATION <br /> I, <br /> hAgent <br /> ereby declare that the statements and information on the foregoing application are true and accurate,to the bests of my knowlas edge and <br /> belief. <br /> Signed under the pains and penalties of perjury. <br /> Print Name <br /> Signature Of 0w /Agent <br /> Dat <br /> SECTION&MUNICIPAL DEPARTMENT SIGNATURES OF CHECK OFF <br /> Conservation DPW(Road Cut) <br /> Board of Health �^ axe_ Ott- !D/9/ --:r <br /> Fire Dept <br /> Board of Appeals <br /> Water Dept. Planning Board <br />