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11/18/2003 11:48 508775 WYNN HYANNIS PAGE 12 <br /> SECnON 4-WORKM'COMPENSATION INSURANCE AFFIDAVIT <br /> (M.G.L,c 152 35C(6)) <br /> Werkea'Compsneatlon Insurance affidavit mun be completed and rabrMeoed wIN Nisb <br /> result in the denial of the issuance of the building permit <br /> Won.Fail=w provide Nle affidavit w111 <br /> • Signed Affrdivlt Anached: Vag O. No <br /> •. . SECTION 5-DESCRIPTION_OF PROPOSED WORK(cheek All nppBeabla <br /> New Conatructlon O .3=1190111141301 O I Repairs) O Akeration(s) O A <br /> ddition <br /> ACceawry Well. O DemolitionO Other p Specify. ',J`G,( <br /> brief Description of Fra t <br /> Pd . prmd Wolk: <br /> 5LID <br /> LmcNR—Overall Dimentien: LerrgN ('rldN <br /> • Height <br /> SECTION 6-ESTIMATED VALUE OF CONSTRUCTION <br /> Item Ha e a v.)ue w bo OAIeW Use Only <br /> P Y permiu lien+ <br /> 1.Building <br /> W building Pdmmit Pee Muldpller <br /> 2.Electrical (b) nand 7bp1 Cort of <br /> 3.Plumbing Cotuuudion hen 6 <br /> 4.Medunlol(HVAC) Building Permit Fee 1� <br /> S.Fire Protsctlan (a)x(b) <br /> 6.TOW.(1*2+3.4+1) Cbeek Number <br /> SECITON To-OWNER AUTHORf2:4710N.To BE COMPLETED WHEN <br /> OWNRR'SAGENT OR CONTRACTORAPPLD;S FOR Rim DINO-PERND7' <br /> I uOwar of rhe eubjcct psepetry <br /> hembyauNorim Ski( watt on <br /> mY behalf,in all msMrs relative to work suthoriz by s Duildiag It n, <br /> a �510� <br /> MRn d <br /> SECflON 7b R/AVTKORR.ED AGENT DECLARATION <br /> 1, <br /> bereby declare that the statements and information on the fere oln aO"'W uthorisdAgent <br /> belief. g g epplindon are true end accurate,to the best of my knowledge and <br /> Signed under the pains and penalties of perjury. <br /> t4ha Hen. <br /> atamwaoewH„u <br /> um <br /> SECTION S-MUNICIPAL DEPARTMENT SIGNATURES OF CHECK OFF <br /> rfimocpL <br /> n DPW(Rod Curti) <br /> alth G axes ©„ <br /> Bard of Appeals <br /> Preening Board <br />