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171 NORTH ST - BUILDING INSPECTION (2) r 13 - 1 tul I sN ZS� C�. The Commonwealth of Massachusetts RECEIVED CITY OF Board of Building Regulations and Standar SPECTIONAL S RVICETLEM Massachusetts State Building Code, 780 C Revised Mar 2011 Building Permit Application To Construct,Repair, RenovateM%DJoV4 aA Q 42,, One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 171 Ivor S! . 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(ft) 1.5 Building Setbacks(1t) 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❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Or c4r Owner ofRed — �: (^ Mn .t naMny Lf-, sr Pm I' N7 r71 q7O Name(Print) City,State,ZIP ry NarN, 6V 91a-22.i-050a No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) W1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other b Specify: Brief Description of Proposed Work': I _ c�Xf1b ( © 1 etiL(64-( u 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: $ C Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 3Jr J ❑Paid in Full ❑Outstanding Balance Due: 5t---1\sr TD (—OWES (c } SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 0A 3_ A License Number Expiration Date Name of CSL Holder aList CSL Type(see below) No.and Street Type Description Sl ,�,�nt U Unrestricted(Buildings u to 35,000 cu.ft.) <" em ffo 01�g70 R Restricted 1&2 Family Dwelling Citn,State, P M Mason ry RC Roofing Covering b WS Window and Siding SF Solid Fuel Burning Appliances y7� j�0-?17� I Insulation Telephone Email address D Demolition 5.2 Registeredr Home Improvement Contractor(HIC) �q86� ro-W-1$— LOU-14 L�M� C� " "r HIC Registration Number Expiration Date HIC Company Name r HIC J egistrain Name /3( -rurilel /a eY3-Lo+t No. dStre t-T QyY6 Email address c�JJ d�dUS�r ✓)1/� �l'71oZ 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 .......... No........... ❑ SECTION 7a: OWNERIAUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 'Pt C- YA cwogo to act on cmy behalf,in all matters relative to work authorized by this building permit application. o Print Owner's Name lectronic Signature) Date SECTION 7b:OWNER'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 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. oe v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics,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"may be substituted for"Total Project Cost" \ Inc a ummtrnweuun v/ In"NSIUMUSCIM t DepartmentoflndustrialAc idents t?fce of Investigations IC ongress Street, Suite 00 Boston, MA 02114-20 7 www tttassgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers AD licant Inforx a>iion Please Print Legibly t Narne (Business/Organi tion/Individual): 1� 0.CI l,y� ik Address, I i City/State/Zip: (} DIg7 o Phone 17t 630-717 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 1 am a employer wiin 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-con ctors 6. ❑ New construction 2, 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling shipand have no etn to ees These sub-contractors have p y 8. ❑ Demolition working for me in any capacity, employees and have.wor ers' 9. ❑ Building addition [No workers' comp insurance comp. insurance? required.] 5 ❑ We are a corporation an its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised t teir I LEI Plumbing repairs or additions myself. [No workers' comp. right of exemption per TV GL I2;❑ Roof repairs insurance required.) r c."152, §I(4),and we ha eno 13 ❑ Other ! I employees. [No workers ( comp. insurance require .] '*Any applicant that checks box t l must also fill out the sec�ion1below showing their workers' • pensation policy information. -Homeowners whosubmit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.. Contractors that check this box must attached an additional sheet showing the name of the sub ntractors and state whether or not those entities have employees. If die subcontractor have employees,they must provide their workers'comp.polio y number. I am an employer that is providing workers'compensation insurance form employees. Below is the policy and job site information. Ifl Insurance Company Na Policy#or Self ins.,Lic!4L. ( ( Expiration Date:_ Job Site Address: J�l NaI S�• City/State/Zip: -'altrht t!!7/} Ol rtZO Attach a copy ofthe workers' compensation policy declaration page(she wing the policy number and expiration date). Failure to secure coverages as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/o 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 iadvised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do'hereb cerli a rr a "ns and enalties o perjury that the in orm ' n prorrtled above is true and correct. � ( . Si ature: tZq I f Date .Phone#: t .7 "'S3� —7r] OJrciaf use only. Do of write in this areal to(be completed by city or to wir official City or Town: Permit(License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. ectrical Inspector 5.Plumbing Inspector 6.Other t ' `Chniart Person- ! Phn a a• flee of Consumer Affairs&Business Regulation License or registration valid for individul use only ' -. before the ex iration date. If found return to: ,:����{OME IMPROVEMENT CONTRACTOR - P -iy !' Office of Consumer Affairs and Business Regulation _�'`Registration: 148688 Type 10 Park Plaza-Suite 5170 Expiration: 10/18/2015 Supplement and Boston,MA 02116 LOWE'S HOMES CENTERS INC p 136 TURNPIKE RD. SUITE 100 ��-->�_ ' 1\ �U SOUTHBOROUGH,MA 01772 Undersecreta v1 ry Not valid without signature { 4 �i �:,t �..ppfi sue` �<�`•.¢ �'fi� �:�••" : S r N h A , r .� T'.e • Miisavhusetft D. Board of Stsi4ding Requi,sl �f ii w E `-a x ti � Office of Consluni r Affairs and Business Regulation 10 Park -Suite 517 Boston, Massachusetts 02116 Home` rnprovement Contractor Registration Registration: 162722 ` Type: Individual ( Expiration; 4M/2015 TrB 2389M MICHAEL THOMAS DEMLLE MICHAEL DLMILLE 5 BRISTOL' ST SALEM, MA 01970 Upd tcAddress and ntum card:Mark reason for change.. x4, c•,suuosn A ddress C Renewal 0 Employment C Lost Card -//7 .. Ofrm"6rcouumuA irs a Badnexs Repulatiop License or registrad valid for individul use only .,,Leg'Mtstratil E IMPROVE) TCONTRACTOR ( before the expiration ate. If found return to: tl� Type: Office of Consumer airs and Business Regulation ration: .4J&ROt 5 Individual 18 ParhPlaia-Spite 170 1 Boston,MA 02116 MICHAELTHOMAS'DEMII.LE MICHAEL DEMILLE .. 5.BRISTOL ST SALE'M,MA 01970 .17adcrseaera 7 1Vot valid w' oW aiguatare t'd U�/4J!lJ Gl:da ny -NASLK,Itl rA tl.U1 • ^„ ?�?'`T"s oATEtwrmCERTI ATE OF LIABILITY INSURANCE 09fOW2o13 C'FRTIViIZA.TE IS ISSUED AS A.MATTER OF INFORMATION ONLY AND COE NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS C RTIFICAT DOES NOT AFFIRMATIVELY OR N NF NEGATIVELY AMEND, EXTEND OR J LTEA THE COVERAGE AFFORDED BY THE POLICIES I BELOW.. THIS CERTIFICATE OF INSURANCE DOES; NOT CONSTITUTE A CONTRA4 T BETWEEN THE ISSUING DISURER(S). AUTHORIZED t HEPRESENTS"nVE OR PRODUCER,AND THE CEOPROATE HOLDER. ' IMPORTANT: If the cea is holder Is an AODff10NAL INSURED,the POfiey(lea)MUM be endorsed, D SUBROGATION IS WANED,subject to th9 terms and conditions of the Policy,certain Poiklfs•may requt o an endorsement A tatemem on this certificate dove not confer rights to the ,-w6 ieate hotdar In Ifau Of such ondoraemen s. i 'RoeueeR Parents Insurance Agency Inc. _ _- 94 Lynn S"ot MORE 9� Y531.8054 ���i�e w g7tH_531.5587 ?aebaoy,NIA OTB80 ,,gate teinsuranIR grgoii.com IRS AfFO"PQ OOUTRAGE . . MAX f s, AtnfjcCasualty .µa ,;n i431C}i'"Oi DDNiliio elOWteRel_. -''Sr 9Tni Rd.. S31o:n,NIA 01970. ' � I I INfUR20.H_- R CcveRFIGES CERTIFICATE NUMBER: REVISION NUMBER: --:ns 11:TO CERTIFY THA7 THE POLICIES OF INSURANCeiuSTEo BELOW HAVE BEEN ISSUE TO THE INSURED NAM®ABOVE FOR THE POLICY PERIOD iV01CATF.O. NOTWITHSTANDING ANY REOUIREMENJ,TERM OR CONDITION OF ANY CONTF kCr OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PFRTAIN.THE INSURANCE AFFORDED BY THE POI CIES DESCRIBED HEREIN 15 SUBACT'TO ALL THE TERMS. GKCI.USkNi3 AND CONDITIONS OF SUCH,POLICIES.LIMBS SHOWN MAY HAVE BEEN REDO BY PAID CLAIMS. ..t' Type OF"OUNAnca i i T - R -•-,••••.•:- lglr}a -••-••• 1 I caM+eawA of�eRnluAenTtr U118000T42-1 I08 13lO8fZ0f2014 oxunAOFH _. "BID 0 1 cl,.vas.MAOE N Occur: SOOOD .._: I ( ERI&G81EaArrillOMmei -, {I- I P�Rsgp a novlN.NRY 300,000 �EH All ?P'FA 'T LIMIT 4 PIXIES PER I OS{RRµ A00RROATE. 3600,000 " ✓� � tYh:CY '2O L„J toc � PRODUCTs•OOMPIOP Aoo $600,000 ^--T I PMr AUN a000Y WAIRY _ IPafmrmt f ...-.... 1 '� f ' UWS LCM IRE, SAufOA AEO I ) I 90OILY INArT'tPw PrUARn f '0H 0AUTOS AUTOSO I I 6E f I~:.. .....-.....� S._—.. I UM OR UAS ` OCCUR I EACH OCCURRENCE f P<CESS UAa AGGREGATE _ S )- t'YORnWie COMPRNeATIOH ... {. tARryO P&R5e0LOYEORS''UAJURURY tom,N� LIM _. }rn'rz" Me��.AMacIi RIF'CCUIIVE ,�-1 NIA I mom 1.- _.,... {Misomymtwli i E.I.dsa .ewEwlo f �ift"ENlwItxs d 1 II (�.. A, , 1 I ex.Wa9ASE• UNET s 11 I { � � i oescRIPTIW1�OPangipt}!r'tAtATaX19I VENICLEs{1iCORO ia./ aotWaalronn 9deElAe:IRryMaftow aaoonIq fs"woo . . . . tit is Uncivstood and agreed upon that LoWs Comlianlsa Inc.and a"and all subsidiaries am named as Additional htsurod WO roEV"to ICupentf7 Oontrector r i f CERTIFICATE HOLOER I ..CANCELLAI ION . Lowa'sCortipaniestnc: .A.,tr is;:eauvance ti SHOULD AN f OF THE ABOVE OESCMeb POLICIES BE CANCELLED WORE �p(}F10X'1'111 S .I THE. E.7WI T NI'(/ATE THEREOF, NOTICE WILL at OEWERED a1 ,• ACCORDANCE WITH THE POUCY PROVISIONS, North Y?I:kdsbaro,Ne 28656 ' I AUT ATryE t_ J it '1 I A D C . AN ri reagilt I 'JF"45(?STAt011 The ACORD name and Wgb are raglstored 1 marks of ACOlW PreLaVe uN,Ia FM(Ija ppjG YWNWIMNr., YwvftsOpGArR;CIA pmmuhv P'AfrtAlf w4wif" F s» 3w �u as 1A72"(,.`a�,;/� i�1.�1 try r•�g^j,*�a.rr-�tt3� .� � <�1'��� A�.�a','�s+'S't yK+� s ze r' U"'oY. {"5 � - ' CONTRACT# 0'4 00 � 3 r `�T`L TG t t"w�.c 1 ��•��hy�A�., �}']kL .>fs'c "� ,y a o.�ck �,��'�`�'�"�}4��� ��'C; t-� U M/l$SACML{SFT[S'SERWG SG1ltGS�NS�LEU'SES GQNTRAGT r" rt' ER BTORE No. sraEEr oREsssrRSEET ADoaEss n it x_oY.. x r S i��® '>-�` r v } LOWE ED REPRESENTATNE NUMBER M 1 � OU 3 or CT' STATE ZIP- STATE •. ZIP TELEPHONE �y}ft� [�TELEPNON DAM LOWF NONE CENTERS LLCSAUHIG NO,1J0800 FEIN S N NE EC T T r 13 GE 4?xrr ty a mabuM',emwieruw mndmnaae atq mwasprnmd,yd_ tm66xcmes em.�en�l well m.`WVI Pem�P1.In .. p meth irc�uaP5 me.pmlwly Wemin.*m,Hx , m w,PmvM1 ere tame ma cumuuul Twee wire SIDEo tlmlmamN¢�sa ]etltw'k aas¢4imh bhwam thou 5e raffi,reGbhemla dw'4xnbed. � �PLEPSE'RFADwl TFJMIS AND CONDmONS ON THE REVERSESIDE OFTHI$RA('e�1N0 FIXlDylING PAGES�EFORE SIGNING �.� - F y -. � INSTALLATION STREETEET ADDD- . MtY. RESS CITT STATE ZIP �.... 'F' rtiep ce ✓ i Wl a (YC q.>4.✓T ' O -Ku xys P tad ;UP. fin . NOTICE TO CUSTOMER-PRICE CALCULATIONS:In order to properly perform the installation of certain Goods,the Contract Price may include more Goods than actually will be installed based on the measured square footage of the Project Area.As a result,the parties agree that the lump-sum Price stated in this Contract Is calculated upon both the value of estimated Goods required to fulfill the Contract(including waste),which may exceed the actual square footage of the Project Area,and the labor which may be estimated based on the amount of Goods required to fulfill the Contract(including waste). By signing this Contract below,Customer acknowledges receipt of this notice and agrees and understands that the Pnce includes these casts which may not be refunded once the Installation Services are performed. Contract Total Or Are permits required for this installation?:[xYes [ ]No *applieable tax included J�JS,t NOTICE TO CUSTOMER:Federal law requires Lowe's to provide you with the pamplet Renovate Right By signing this Contract,Customer acknowledges having received a copy of this pamphlet before work began Informing Customer of the potential risk of the lead bastard exposure from renovation activity to be performed In Customer's dwelling unit. NOTE:N rotted wood is discovered during Installation additional charges will apply.You will be given a quote and a change order must be completed and signed by the customer for any additional charges. - Customer must Initial. 'Arty work or material not apadflalf Is nM Included in this contrarA Any changes or atltlNons will ba at an additional charge for the material and labor. PHOTO RELEASE:Customer gmnts to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where Installation Services will be performed and all work performed at the Promises related to this Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide,in perpetuity.Customer authorizes Lowe's to copyright,use and publish the photographs in print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose,including,but not limited to,marketing, advertising,publicity,.illustration,training and Web content.By Inhaling here,Customer agrees to the foregoing. [Customer to initial to the left]. Work Is to commence upon reasonable availability of Connector and/or any special order or customer made Goodie)which is anticipated to be [fill In date].Estimated completion date Is [col in date]. Said estimated substantial mmplegan date is not of the essence.A statement of any contingencies that would materially change said estimated substantial completion date is as follows: if applicable,insert a statement of such contingencies).IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. GO}KtI jE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: Customer to Pay In Full; OR [ ]Customer to use the following payment schedule: (1) posit $ to be paid upon signing contract.Deposit should be 1/3 the total contract price;and (2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation,I(Wa authorize Lowe's to do one of the following(check appropriate box below): [ ]Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or ( J Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed;and (3)Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction. NOTICE REGARDING ARBITRATION AGR M NT FOR rLAIMS COVERED BY M L. 14 LOWE'S AND OWNER HERE UTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT SUC DIS UTE APRIVATEARBITRATION SERVICE WHICH HAS BEEN APPROVED BV THE SECRETARY OF THE FXECUT- IVEOFFI 9QFGg M RAFF IRS D BUSINESS REGULATIONS AND THE OWN SH L BE REQUIRED TO SUBMIT TO SUCH ARBITRATION BY - Date: -� //'� 1y,�yr�s 9Cy?n.tem,1- /• // Own nature '�— THE SI NATURES OF THE PARTIES ABOVEWPPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANT TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPARATELY SIGNED BY THE PARTIES. - DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.YOU A rTITLED TO A COPY CjX THIS CONTRACT AT THE TIME OF SIGNATURE. - WITNESS OUR HAND( )AND S )BELOW THIS DAY OF ./ Low 's Hom a .y Af Lowe's Authorized RepMliefitWe V 1 Co-owner or Witness Customer acknowledges recelpt of a true copy of this contract which was completely filled In pnor to Customer's execution hereof.You,the buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the attached notice of cancellation form for an explanation of this right. rn�rnov oaxu e.r,,..•.mr,..,.a=.H x,.�..w.x.N.