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Application for Building Permit
Application No: TB-17-3962 Date Recieved: 11/14/2017
Job Location: 14 CHARLOTTE AVENUE,COTUIT
Permit For: Building-Insulation-Residential
Contractor's Name: MICHAEL T MCMAHON State Lic. No: CS-068111
Address: , PLYMOUTH, MA 02360 Applicant Phone: (781) 831-1234
(Home)Owner's Name: LONG, DAVID J& MICHELLE I Phone: (508)904-9799
(Home)Owner's Address: 10 MAGUIRE ROAD, WAYLAND,MA 01778
Work Description: Weatherization,air sealing,weather stripping and blown celluloseZIE
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Total Value Of Work To Be Performed: $7,600.00 — m
Structure Size: 0.00 0.00 0.00
Width Depth Total Area
I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before
he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568).
1 understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by
filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to
accept coverage.
1 hereby certify that I am the owner of the property which.is the subject of this application or the authorized agent of the property owner and have
been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the
Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and
specifications. All information contained within is true and accurate to the best of my knowledge and belief.
All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24
hours in advance.
Signed: Mike McMahon 11/14/2017 (781)831-1234
Applicant Date Telephone No.
Estimated Construction Costs/Permit Fees
Total Project Cost : $7,600.00 Date Paid Amount Paid Check#or CC# E Pay Type
Total Permit Fee: $88,76 11/14/2017 $38.76 XXXX-X M-X)M- Credit Card
1417
Total Permit Fee Paid: $88.76 11/14/2017 $50.00 XXXX-X)M-)OM- Credit Card
1417
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