73 MOFFATT RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SM
Revisedd Marar 201/
Building Permit Application To Construct,Repair,Renovate Or Dem 1sh a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature tI
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel u ers
Lla Is this an accepted Street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public M Private❑ Zone: Outside Flood Zone?Check if yes0 Municipal W On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: �1
r+i—even 2t ?902A l gab„ �r .7m4 w Vmw D//i 0
Name( ot) City,State,ZIP
/�-3 mo)`F,4ff Q�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) .H 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
2 Al 1/ulD Ohl S t ! /�D01Z
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$ 2 1!5'Z
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
7�
e--A4
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
fi/ UGL1 vat License Number Expiration ate
Name of CSL Holder */
�� List CSL Type(see below) ,(/
No.aynn d Street Type Description
,Al# o �7— U Unrestricted(Buildings u cu.ft.
�G[ M R Restricted 1&2 Family Dwelling
City/To",Sta[Stat ,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
L,
SF Solid Fuel Burning Appliances
9�8 -3 -3 5T� CO e4gyele nsulatton
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street
Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........@F No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date Y
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. o¢ v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF S.UX.M, NLvLNSSACHUSETrs
BUUMLNG DEPARTMENT
\ bj 130 WASHIINGTON STREET, 3' FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINfBERLEY DRISCOLL
MAYOR THo.%tAs ST.Pm&m
DIRECTOR OF PIBLIC PROPERTY/BUUMLNG CONMaSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
�� 5v.�eet>ic�l
(name of ha ler)
The debris will be disposed of in
AW (,da she.
(name of facility)
& O 76e4' 5L-
(address of facility) 0
signature of permit applicant
date
debrimil'Am
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �r Please Print Legibly
NaIDc (Business/Organizationlndivdual): Al—d `Q j&�e— Q�7P ��GCr(�Celfle
Address: t/� (�(ir'jtJ�SGyv�i� J 4V
City/State/Zip: Phone#:
� Y 3
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).
s have hired the sub-contractors 6. ❑New construction
2.0 lam a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have S, ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cVeZsceev�
r fhhe pat.ns and !ties ofperjury that the information provided above is true correct
Si atr „c._p� Date: 7 ZI
Phone#: D - 3 /
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
F tithe ltommonlnealth of Massubusetts
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Room 1717, Boston, Massachusetts 02108-1512
Foreign Limited Liability Company
Application for Registration
(General Laws Chapter 156CL Section 48)
Federal Identification No.: 900737772
(1 a)The exact name of the limited liability company.
N.E.Cornerstone Home&Property Maintenance LLC
(1 b)If different,the name under which it proposes to do business in the Commonwealth of Massachusetts:
(2) The jurisdiction`where the limited liability Company was organized:
New Hamshire(3) The dare of organization in that jurisdiction:6/22/201 1
(4) The general character of the business the limited liability Company proposes to do in the Commonwealth:
Construction renovations maintenance of homes and property
(5) The business address of its principal office: -
49 Bumt Swamp RD — Customer COPY
East Kingston NH _ _ . - EXCESS
Label 11-B, March 2004
03287 _ - - ---
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THE COMMON WEALTH OF MASSACHUSETTS
OFFICE OF CONSUMER AFFAIRS AND
'mod Lei BUSINESS REGULATIONS Registration No:
n Y 10 Park Plaza,Suite 5170
A
Boston,Massachusetts 02116 Effective Date:
LrrbW 'J; Application for Registration as a Home Improvement Expiration Date:
Contractor or Subcontractor
(MGL Chapter 142A,780 CMR R6)
(PLEASE READ BOTH PAGES CAREFULLY)
I. BUSINESS NAME: &.. F. /'.o('uerSkne, Mope X pro toer Af in 4d.1anc.c.
Print thhee fn'a m which the application is conducting business(SEE INN TR CTIONS)
2. NUMBER OF EMPLOYEES:
3. APPLICANT TYPE:—6 N-DIIVIID`UUAALL -V CORPORATE_PARTNERSHIP TRUST
(CHECK ONE-MUST BE SAME LE/GAL/ENTITY AS THE ENTITY IDENTIFIED IN#1) _
4. SOCIAL SECURITY NO.: FEDERAL TAX ID NO.: �t�y�9 /�n y t L
5. APLICANT PHONE#: 9 �- '3/ APPLICANT EMAIL ADDRESS:
6. MAILING ADDRESS: U9 �(//'n/�- 31-IAm60 & A)�.1/ 03 Ora 7
t STREET CITY STATE ZIP
7. PEP MANENT ADDRESS:
STREET CITY STATE ZIP
PLEASE NOTE THAT A P.O.BOX IS NOT ACCEPTABLE FOR PERMANENT ADDRESS.YOU MUST LIST A STREET ADDRESS
8. IF TI-IE APPLICANT IS A CORPORATION OR A PARTNERSHIP,PLEASE PROVIDE THE NAME,ADDRESS,SOCIAL
SECURITY#AND TITLE OF THE INDIVIDUAL WHO WILL BE RESPONSIBLE FOR THE CORPORATION'S THE
TR T'S OR THE PARTNERSHIP'S WORK(Please review the instructions before answering this question)
LAST FIRST SOCIAL SECURITY# TITL �W
9. IF APPLICANT IS DOING BUSINESS UNDER A D/B/A,PLEASE STATE THAT D/B/A,AND ATTACH A COPY OF THE
FICTICIOUS NAME CERTIFICATE FILED WITH THE CITY OR TOWN CLERK:
D/B/A NAME:
10.(a)DOES THE APPLICANT OR RESPONSIBLE INDIVIDUAL HOLD ANY OTHER CONSTRUCTION-RELATED STATE,
CITY OR TOWN LICENSES OR REGISTRATIONS? DYES NO
(b)1F YES,PLEASE FILL IN INFORMATION BELOW.ATTACH ADDITIONAL SHEETS IF NECESSARY.
LICENSE TYPE ISSUED BY LICENSE/REGISTRATION# EXPIRATION LICENSEE NAME
DATE
��� Y
1 I. LIST ALL PARTNERS,TRUSTEES,OFFICERS,DIRECTORS AND MAJOR OWNERS(10%OR GREATER OF
OWNERSHIP)OF AN APPLICANT PARTNERSHIP OR CORPORATION,BELOW. USE ADDITIONAL PAPER IF
NECESSARY AND INCLUDE NEEDED PAPERWORK(SEE INSTRUCTIONS). PLEASE INDICATE BY AN"X"IN THE
LAST COLUMN THOSE INDIVIDUALS WHO REQUIRE AN APPLICATION FO ADDITIONAL REGISTRATION I.D.
CARDS. USE ADDITIONAL SHEETS IF NECESSARY.
FULL NAME TITLE %OWNER n r� ADDRESS SUPP.CARD
/c afYhE �I�IIG t3la'b loo, x/ Jan.
03ga <t
12. (a) HAVE YOU BEEN REGISTERED PREVIOUSLY AS A HOME IMPROVEMENT CONTRACTOR? -YES NO
(b) IF YES, PLEASE PROVIDE THE NAME AND REGISTRATION NUMBER UNDER WHICH YOU WHERE
PREVIOUSLY REGISTERED:NAME: /`iM ,/fJ`/je h� HIC REGISTRATION#:_ 630 VS
13. (a)ARE YOU CURRENTLY OR HAVE YOU EVER BEEN AN OFFICER, PARTNER,OR CO-VENTURER OF AN
APPLICANT WHO PREVIOUSLY APPLIED FOR OR FIELD A HOME IMPROVEMENT CONTRACTORS
REGISTRATION?_YES NO
(b) IF YES,PLEASE PROVIDE THE NAME OF THE APPLICANT/REGISTRANT AND THE REGISTRATION
NUMBER:
NAME: HIC REGISTRATION#:
14. (a)ARE YOU CURRENTLY OR HAVE YOU PREVIOUSLY BEEN EMPLOYED BY A REGISTRANT OR APPLICANT
FOR REGISTRATION AGAINST WHICH DISCIPLINARY ACTION WAS TAKEN?_YES _KNO
(b) IF YES,PLEASE PROVIDE THE NAME OF THE APPLICANT/REGISTRANT AND THE REGISTRATION NUMBER:
NAME: HIC REGISTRATION#:
15. (a)HAVE THERE EVER BEEN ANY FORMAL COMPLAINTS AGAINST YOU WHERE DISCIPLINARY ACTION WAS
TAKEN BY THE DEPT.OF PUBLIC SAFETY OR CONSUMER AFFAIRS,OR ANY COURT JUDGEMENTS OR
ARBITRATION AWARDS ISSUED AGAINST YOU?_YES _KNO
(b)DO YOU OWE MONEY TO THE GUARANTY FUND?_YES �NO
IF YES TO EITHER,PLEASE IDENTIFY BY DATE,CASE NUMBER, OR DOCKET NUMBER:
IMPORTANT FEE NOTICE:CHANGE IN LAW ABOLISHES CSL'S HIS REGISTRATION FEE EXEPMTION.
As a result of a recent change in the law(Section SO of Chapter 27 of the Acts of 2009),the holders of Construction Supervisors
Licenses are no longer exempt from the HIC Registration fee.CONSEQUENTLY.ALL CONTRACTORS INCLUDING
CSL'S WHO ARE APPLYING FOR A HIC REGISTRATION MUST PAY A REGISTRATION FEE OF$150.00,AND
A GUARANTY FUND FEE.(See instructions for Guaranty Fund fee schedule)
16. REGISTRATION FEE ENCLOSED: $�— GUARANTY FUND FEE ENCLOSED:$
PLEASE INCLUDE TWO(2).SEPARATE CERTIFIED CHECKS OR MONEY ORDERS ONE MARKED
"REGISTRATION FEE AND ONE MARKED"GUARANTY FUND". MARK BOTH CHECKS PAYABLE TO
"COMMONWEALTH OF MASSACHUSETTS"
1 hereby swear err the pains and penalties of perjury,that all information.set forth on this application and submitted in support
hereof* t and ace rate to
the best of my knowledge. Further,l certify under G.L. c.12C,§49A,that!am in compliance with all laws of a Gamma ealth relating es,rep rung of employees and contractors,and withholding and remitting ofchild uppart
ignature of Applicant It a corporation or partnership,position held.
P Date