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SECTION 4—WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L.c.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 ❑ Repair(s) O Alteration(s) ❑ Addition p <br /> Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify: <br /> Brief Description of Proposed Work: <br /> Structure—Overall Dimension: Length Width Height <br /> SECTION 6—ESTIMATED VALUE OF CONSTRUCTION <br /> Item Estimated Value to be Official Use Only <br /> c mpleted by permit applicant <br /> 1.Building (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 /> � <br /> 5.Fire Protection (a)x(b) <br /> 6.Total=(1+2+3+4+5) J Check Number <br /> SECTION 7a—OWNER AUTHORIZATION-TO BE COMPLETED WHEN <br /> OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT <br /> vkirgki <br /> 1' 'e ,as Owner of the subject property <br /> hereby authorize d 1 u to act on <br /> my behalf,in all matters relative to work authorize by is building rmit ap c Lion. <br /> r <br /> !!:&M zz A <br /> Signature of owner / Date <br /> c SECTION 7b—0 R/AUTHORIZED AGENT DECLARATION <br /> as Owner/Authorized Agent <br /> hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and <br /> belief. <br /> Signed under the pains and penalties of petjury. <br /> Print Name <br /> Signature of owner/Agent Date <br /> SECTION&MUNICIPAL DEPARTMENT SIGNATURES OF CHECK OFF <br /> Conservation_ _ DPW(Road Cut) <br /> 1i ax d� a 9 <br /> Board of Health es <br /> Fire Dept. Board of Appeals <br /> Water Dept, Planning Board <br />