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12 NORTHEY ST - BUILDING INSPECTION a The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY y ;0 Massachusetts State Building Code, 780 CMR, 7ib edition OF SALEM t� Revised Junuury Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008 One-or Two-Fumdy Dwelling This Section For Official Use Only Building Permit Numbeg;.... Date Applied: Signature: Tv BuildirigCummissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Add 1.2 Assessors Map& Parcel Numbers 1AUn f Mi y- SA-. 1.1 a 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 R) Frontage(11) 1.3 Building Setbacks(B) From 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: Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Own eer of�Record. '' 11 '' II ++ Name(Print) Ad rcss for Service: i - �r_s-,1 - 3 rsa Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': it w; SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S rb I. Building Permit Fee:S Indicate how fee is determined: �. Electrical S ❑Standard Cityrrown Application Fee ❑Total Project Cost(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: S 4. Mechanical (HVAC) S List: ^1/ �� 5. Mechanical (Fire S Suppression) Total All Fees:S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S l od a 3�. ❑Paid in Full ❑Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) ( -7 l )'q /© )7 / IA.() '\.CI C CO✓'C�ne Lieense Number GYplration Date Name of CSL-I lolde `/ I.ist CSL'I'ype(see below) Description pe :\dJress l�V�✓•��ICI r ( ',ktMD unrestricted u to 35,000 Cu. Ft. Restricted Ik2 Famil Dwelling Signature M• Only f2(�-�$ - 1�$7 Residential Roolm Covering Telephone Residential Window and Siding Residential Solid Fuel Burning Appliance Installation Residential Demolition 5-2Stegiste HomelmproveM an actor I( �� C / C G ° Psi'— ) Registration Number FIIC Company Name or f IIC Regist�artt Name ) aT . ���k; � a /N5 713l« Address Espirutio Dale (Pt) �R7 /s kJ Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, Ptiµ k [A,-A r.,,S , as Owner of the subject property hereby authorize Low S I^4cs L � �.-'� to act on my behalf, in all matters relative to work authorized by this building permit application. - Signature of Owner Date r c p / SECTION7b:OWNEW IOR AUTHORIZED AGENT DECLARATION 1 13zz�e ILGA,u, / L.ptd e S l`1'O as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. ~- Print Name 7/��/� Signature of Owner or uthorized gent Date (Signed under the pains and penalties of 'u NOTES: I. 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 j1 have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 10.116 and I IO.RS, respectively. 2 When substantial work is planned,provide the information below: Total floors 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" 9 'a'�NN Ns im�� �qmin' gg sas . w �*ttgrna >5 a* CONTRACT# ,. .rd a,-� �� '�db.+'�.��W'P��%'" r.. ,�n ;� P •.mw. ti o- t �'�`� M14SS�ACHUSETTS EXT�RIORSOLUTIpNS"INSTIIL�.EI�:Sr4L�.S`CONTRAET=c� "� �� '�``ti� � I .�� . :. " �s:�`"�.,s r.u.,:,.4ny ;�., .'t➢� asiigx! .'>:*,Hr� ? �a �7'a'h-r«n��A�.� r ;''V'+s.?�-twr� '. INSTALLED SALES SPECIALISTy'') NU}MBER �} € CUSTOMER [, _ ; +R " , STORE NO: STREETAODRESS - 4-4- STREET ADDRESS � "'�` }. �f ✓OJr}"slj f CITY STATE ZIP , '* CITY STATE ZIP tG v '16%•. mgTELEPHONE . ,r TELEPHONE - DATE LOWE S HOME CENTERS INC'S MA HIC NO 148588 - GSH BANK FEIN 5E0748358 1 ^XLS DARD F �.� CHARGE - 3 Thlsrs opty ag0ate fwmemerchandlseanpsewipes panted ow`a7las'becomesan;agreementuponpaymentllpon payrrenQ theenhre agresm�n[mdUdin�lha speclRcailymmpletedpages of tfils: +. �+doduwmt,the Lelrp;end Con[IWons mclede&mq mWdowptent' any oteraddenda and menu heretp sh�ltbexe(arred to harem asmis,Cenfn3dt`" '� f ?PLEASE READ/lt.),TERMSAND CONDITIONS ON VERSE SIbE FINISPAdFAND FOL40WING PAGES BEFORE SIGWNG i6` ,. Y }r - '¢ SA'g a, x INSTALLATION STREET ADDRESS // ,,fJ// -CITY STATE ZIP - � ,c rlc,7 A.e"t - f,fJrl +w(•f�,... .:. ,I;A F7 't:ryNJ ... i Contract Total Are permits,re auired for this installation?: XIY89, [ 'I No 'applicable tax [ncluded NOTICE TO CUSTOMER:Federal law requires Lowe's to provide you with the,pampiet Renovate Right.,Important Lead Hazard Information forFamil- I •/es, Child Care,Providers and Schools.By signing this Contract,Customer.acknowledges having.received a copy of this pamphlet before work began - "informing Customer ofthe potential risk of.the lead hazard exposure from renovation.activity to be performedin-Customer's dwelling unit. Work Is to commence upon reasonable availability of Contractor and/or availability of any special order or custom made Goods'wtiich is anticipated to be "T"L`G' (� [fill in date]. Estimated completion date is [fill in date]. —r ' Said estimated substantial completion date is not of the essence. Contingencies that may materially change said estimated-completion,~date follow: " - - - - (If applicable;insert a statement of such contingencies). IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. - , .i COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00 "- �' 't4 [Customer to Pay m Full; ,. OR : [ ]Customer to use the following payment schedule - �, ark , „'� K+ + `' (t) eposd"$ -. to be paid upon siging contract.Deposit should be 1/3 the total Contract price,and. r c. + (2p Paymeritof$ to be paid anytime after this Contract is signed.andbefore commencement of installation, I/We authorize-Lowe's to.do one of the following(check appropnatebox below):.. .` - :. � - ' - [' ]Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; - w ors _ [':']Deposit.my/our check for theamount of the payment indicated aboveanytime aftecthe date this Contract is signed;and F.inahpayrnent.of$100.00 fo be paid upon completiorrof the installation and both parties'satisfaction., NOTICE`REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M:G.LicA42A LOWE'SAND OWNER HEREBY,MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS;;CONTRACT,,THAT, LOWESMAY,SUBMIT S�CH61SoUTETOAPRIVATEARBITPAT[bN`SERVicEWHicL4,HASBEEN:i4PPROVEo'BY E.SECRETARY,OF THE EXECUT,,,� WE OFFICE OF CONSGMERPfFAIRS AND BUISNESS REGULATIONS AND THE OWNER HALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS 71L7E"[Yi10^ G.L. .1 �+A '- . Date ! t t acr rs- Lowe's By: Data /c f(2 t o # ''' TELEPHONE - TELEPHONE z 4.1 "'*'^F'K DATE Jg LOWE'S HOME CENTERS INC SMA HIC NO 148688 , CASH CPRD L Lcc CHARGE f � FEIN 56 0748358 Cn+q qr r q z This�s oNy a gaols for the merdrandlse and serncas printetl below-:rho#becdmes ari agreement JpoDpayment°UpoQpayment;me enpre agreement{.Incdutllhg the specficallycompletedpages oitms `�+ 'document,the Terms and CondNons mdaded with tnts;tlocumen`t and any Omer atlaeiitla,adp attachments hereto,sheikhs refeheUt6 iierem as yis"Contract 1 {"'" e " �' '. ��� ar' ".PLEASE READ ALLTPJ2MS ANp CONDITIONS ON'TN,E REVERSE SIDE OFTHISPAGEAND FOLLOWINGPAG€S BEFORE SIGNING ,;""p^" ` r" x+ ee »�' t INSTALLATION STREET ADDRESS (. CITY f1 $S'�TTATTTEjs /zip F•�-'°• Ce _ '�Fi� •4c"L.Y7,S 4J l9 ��aa / F `j f'J ."� �t�o-rJ 1. ti...) t ib l f'.. Contract Total Are permits required for this installation?: ]Yes [ ] No "applicable tax included 42 NOTICE TO CUSTOMER:Federal law requires Lowe's to provide you with the pamplet.Renovate Right:Important Lead Hazard Information for Famil- ies, Child Care Providers and Schools.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 hazard exposure from renovation.activity to be performed in Customer's dwelling unit. Work is to commence upon reasonable availability of Contractor and/or availability of any special order or custom madeGoods'which is anticipated to be Itfd, Z� [fill in date]. Estimated completion date is -[fill in date]. Said estimated substantial completion date is not of the essence. Contingencies that may materially change-said-estimated completion date follow: (If applicable,insert a statement of such contingencies). IF THE CONTRACT TOTAL IS 1 000.00`OR LESS Customer must pay in full. - -- COMPLETE THIS SECTION ONLY.WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: . [ Customer to Pay in Full; OR - [ ].Customer to use the following payrnent.schedule: - - - e osit to be aid.upon si in contract Deposit should be 1/3 the total contract rice and O P $ P P 9 9 P p (2)Payment of$ .to be paid anytime after this Contract is signed and before commencement of installation, I/We 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 - [ ]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 paidd-upon completion of the installation and both parties'satisfaction., - NOTICE REGAIR ING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c.142A - LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,.THAT LOWE'S M'AY7SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION,SERVICE.WHICH-HAS BEEN APPROVED,BY THE SECRETARY,OFTHE EXECUT ,, .... IVE OFFICE OF CONSUMER PtFFAIRS AND BUISNESS REGULATIONS AND THE OWNER HAL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS P�I" G.L. 14 A. -' (Jg ' By: " tee. n '- Date: f�7/" - Lowe's HoMe Ceb e� - _ - l f - - By. -.r R. f. � ...... Dater(fit 10 Own.g,Sigriatu - THE SIGNATURES OF THE PARTIES ABOVE APPLY 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 I EVEN WHERE THE ' SECTION ABOVE IS NOT SEPERATELY 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 PAGESOFTHIS CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. ' WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS %2- DAY OF U 1T E^' - Lowe's Horn C nters, I C: , t Speciaksti Nbo - Ov her -�`- --""' Spouse - 06/22/2010 14:02 FAX 6173891269 GREENE INSTALLATION CO - + LOWES D INST 16002 i Ofrce oTConanma"5inem egu a on TGHDMEIMPROVEMENTCONTRACTDR 9 Registration: .,.,1029$7 Type: Expiration: .J;'�( 72 Private Corporatiod E INSTAd.!„F;11s1C" t Ronald Greene S 185 Bow Street Q Evtnett,MA 02149 Y7adereccntary i O6/22/2010 14:02 FAX 6173891269 Gl{t! Nl 1NS1ALt \t1V1v w - aunna , .,. 1_ i Plassachuxetts- pt�partmcnt of Puhlic�afdv Board of Building Rt.4gulations and Standard. Construction Supervisor License - Lioense -.CS 61719 Restrictedto; 1G - RONALD A GREENE 10 RITA DRIVE MEDFORD, MA 02155 4 Expiratian: 1M2mml (" mmi.,.innc� Tr-"- 6717 I i i I T i 1 i 06/22/2010 14:01 FAX 6173891269 GREENE INSTALLA'1'1uN UU - + Lun>ra u Iran Lei Vim+ The Commonwealth of Massachusetts pepartment oftndttstriai.r4ccidents Offleg ofTnvestigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia llkeWmpensation insurance Affidavit: Buildcrs/Coatractors/Flectricians/PIambers licant lnfnr ation Please Print Le 'b lv AppoLL# N•ame{ISusincsJCrtKnnivationllndividutd): Address:_ — Y PrCBI� t9 OV1 to/? 3�r7. 9771 [:i ty/StaLi:%Lip:_�..�..--- ^!", _ `i 9 Phone#: Are you an employer?Check the appropriate box: Type of project(required). . 4. I am a general contractor and I i �►�'jm a employer with`/�d_ u 6. []Nuw construction employeev(full and/or part••tinle)." have hired the tachsub-Ld shectars 7 [r� i�Crntideling t. I ain a Sole proprietor ue partner- listed on the attacht-d 5have ship and have no employees 'fliesc sub-conlraetrrrs have g: � lyemoGtinn CM and have workers 9 Kuildtng addiction working.for me in any eApaeily. comp-insUnAnce.t �No workers' comp, intiurailce 10.0 F•iet:lrieal n:pairs or additions reluired.l 5. [� W r:am nave cxorciii and its 1.� I am a hnmoownrx doing all work utlFieem have exercised their 11.[J Plumbing repair~or atidiiiotis myself.om ownerwor�o s' comp• righl of exemption per MGL 12.[] Roofrcpah's insurance rcquirod.l t C. ploy e1(4),and have no 13.© Other_„ employees-[Na woror kers' comp. instnanceiequilyd._ "Any nppliemit that chocks hua 01 mint also rill out the seetlon below showing their workers'wtnpensedan ixdicy anfnnnnnpn, t Hnmenw'ncn whn subtnir rhN a 116vit mdieatmg tlloy are doing nth work and then hire ohraldo angtMatWa hWn Ub,ait a new iifduvtt mdtasang micb. . it'uahecmn chat check Uis non must noshed an addittonxi shwt showing The nad>c of the Sub-contractors cad nano whvlitor•m nut mote,sntaies have cnlpluyeas. trlhc suit-wntneun itevo gmpioyecs,they mast provide iheb workers'anmp.policy aamDa'• 1 am an employer that is providing workerv'compensation insurance for my etnpinyeer Below it the pocky trod jab.site information. / IttsurancxCon?panyNama:—..C:h�/� rJfG _ 2L49� �� _ I,xpiration I)ate; JI-4 policy 8 urSeif--ins.l,lc:�:_... �/ 3a/3LL,�„" JobRlteAdUrzss:_ c �l•1 je Sfrt'ed� _City/State/%ip:LJ°jr7® �7�Y Attach a copy or the workers'compensation policy declaration page(showing the policy number and expiration date). t;aillae to secure coverage as rugoLied under SeCtiml 25A of MOL e. 152 can land in the imposition of criminalycnalties ora tine up to$1,500.U0 and/or one-year impriaonment,as well as Civil penalties in the form of a STOP WORK ORDER and a fine of tip u>5250.00 a day against the violator. Be advised that a copy ortllis statement may be forwarded to the Offlue of invest-tuitions of the L)IA for insruanCe co erage veritieation. I do hereby certify under the puins and penalties of perjury that the Information provided above it true and correct. Phone1l: — Offeiniuse un Y. Do'noi wnic inihlr-area io be cnrriy�by7E.lectri a City or'fown: — Pert issuing Authority(circle one): 1. Board of health 2: Building Department 3.City/Town Clepector 5. plumbing tu:ipcctor 6.Other Contact Person: I I{ _g/Z d 000 089 8L6 9Z 66 Z2-90.OLOZ Ub/ZZ/ZUlU 14:UZ YAA 01100WIZOM aa�ccnu a+ .+a�+u+n+..." "" "'•'-- - -""-From.: 05/04/2010 15:32 #131 P.0011001 i 18 CERTIFICATE 16ISSUED A8 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE �RTIFICATE HE pER.THIS CERTIFICATE pDE8 NOT AMEND, t XTENp OR ALTER THE COVERAGl AFFORDED Y THE`POLICIES BELOW,THIS CERTIFICATE OF IN8URANCE DOES NOT CONSTITUTE A.CON7RACT BETWEEN E ISSUING INSURER AU7HORIMD REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER, MPORTAN7: If the Cartitieatw holder is an MDITIONAL INSURED, the poky('res}must be andaread 1f8USROGATION ti WAIVED, subject to the terms and conditions of the policy, certain Poiieies may require and andomemem A statement this cagtfiaate does not confer m to the cerlificata t+older in lieu of such angareemant. PRODUCER New Dgtsnd H*Msps Ins Agsnay 335 Maw st Stomham MA 2180 COMPAIN AFFORDING INSURANCE INSURED COMPANY A GRANITE STATE INSURANCE COMPANY t9daa ns In"Ilmlton Cc Ina- 105 BawSnaet - - - EvslstL MA 0214E-000p THIN ISTO CODIFY THATTFE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN IBSUEDTOTHE MURM N11MEDA90VE FOR . TM POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERN!OR COMMON OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WNCHTHB CERnMAYe MAX BE ISSUED OR MAY PERTAIN THE MURAPICE AFFORDED THE POLIO DESCRIBED HEREIN to BUSEVrTO ALLTHE TERMS,Mr.LUSIOIVB AND CONDITIONS OF SUrtI POLICIES,Uwra SHOWN - MY HAVE BEEN REDUCED BY PAM CLAIMS. - TM:163 47[M tlelaA>!aE 1'aL,IG/MOepyl PTYIOYQIpalafR pA7R Pa1VPL7PMTI0N pAY! MATWNLLWT8OPaIETbw AEAaaE=L a - 4513213 3AW2010 3/04/2011 ATU"RT ulna PApYfrla tuop�aweq - weCIOPxT S mckow WAaa POLI6YLorr 5 500,10 - aaAaa aMP OYaa n¢+TtON OP TIFANB CERTIFICATE HOLDER cF-u ATION LOWESCOMPANIES enouLtf�wrocrbSAaov atecAroeaaoLcasese.eceLteaseraaasm ATTN:IS INSURANCE EWMTKM PATe F.MOF.MMM WLL ee VrsNAKW IK ACCMAWA PO BOX 1111 weTa THE POLCY PawlBOWN NORTH WIL I MSBORO.NC 280" AUTtORITEDENYAYIVE {