15 NORTHEY ST - BUILDING INSPECTION (2) (, 1 u2T�
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The Commonwealth of Massachusetts
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Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
.(This Section For Official Use Only)
Building Permit Number. Date Applied: Building Official:
_ SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
IS A/w-+ Y ST 0qCayIM 1M� 0f9-)o
No.and Street City/Town Zip Code Name of Building(if applicable) _
h - SECTION 2•PROPOSED WORK
Edition of NtA State Code used_ If New Construction check here❑or check all that apply Ia the two rows below,
Existing Building❑ Repair❑ I Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ 1 Change Of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 13 No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
,i S 4.a i l 3 A ICE/ _ir tl I
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Cheek here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ o_
Existing Use Group(s): Proposed Use Group(s):
SECF[ON9:BUILDING HEICHTANDAREA rn
Existing proposal.''
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) r ran
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: E atiomdn❑
F: Facto F-1 ❑ F2❑ - H: High Huard H-1❑. -H-2❑ H-3 ❑ H-•4❑ H-5
1: Institutional I-1❑ 1-2❑ 1-3❑ 14 Cl M: Mercantile❑ 1 R: Residential R-ICI R-2❑ R-3❑ R4❑
S. Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Cheek as applicable)
IA Cl IS ❑ IIA ❑ US ❑ ILIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Informati Trench Permit: Debris Removal:
on: Sewage Disposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be
required❑or trench or specify:
Private❑ or indentify Zone: - or on site system❑ permit is enclosed❑
Railroad right-of-way: Ilazards to Air Navigation: %I-\I Omvnission Ra.;wnr
Not Applicable❑ Y Is Structure within airport approach.area? Is their review completed?
or Consent to Build enclosed Cl Yes❑ or No❑ 1 Yes❑ No ❑
SECTIONS:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Gruup(s): Type of Construction: Occupant Load per Floor:
Does thebuilding,contain an Sprinkler System?: r7Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION ,
Name and Addr• s of Property Owner
Anna r1Q e'/ J'T $cile/v, ,4 b jq�0
Name(Print) No.and Street Vn 4 City/Town Zip i
Property Owner Contact Information: 9 90
- 60050
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
N:une Street Address - City/Town State Zip
to act on the property owners behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less thin 35,000 cu.ft.of enclosed space and or not tinder Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - - - -
q bCIIe Com "y Name
Name of Person Responsible for Construction Li ense No. and Type if p licable D 177
3 0 4 .13o-s "- Rr) Y 1Vr4 / ��d N
Street Address City/lown State Zip
rpil- 74 13 175 _ 8)n_ q 34is
Telephone No. business Telephone No. cell e-mail aaldress
SECTION 11:W'ORKERS'COMPENSAl ION INSUItA:NC.F.AFFIUi\VtT M.G.L.c.L52.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be:bmdd:1eingpermit.
d
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of th
Is a signed Affidavit submitted with this application? - Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Budding $ ( c"f o0
Ouilding Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ / S`60 (contact municipali )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this
a ',lication is true and accurate to the bes f my knowledge and understanding.
1 '0 6L4 ka. Biel) C) e r u j> -33se - 7643 /v
Please sy rut and sigy,name T'i�le p Tcle hone No. Date
pJ0 y D& �o.l �a5 ��b,'t Ian d i� A p (A hone
Street Address City/Town /� State Zip 1
Municipal Inspector to fill out this section upon application approval•
Name Date
The Commonwealth of Massadliusetts
Department oflndustrialAccidents
i I Congress Street,Suite 100
Boston,MA 02II4-20I7
www.mias'sgov/dia.
Workers' Compensation Insurance Affidavit:Builders!Contractors/Electricians/Plnmbers.
TO BE FILED WITH THE PERMITTING AVi'HORITY.
Al2licant Inform ation _ Please Print LeLribly
Name(Business/orga-uzabon/Individual): I 'b:�
Address: 36l `PaSt RcA
City/State/Zip:� 1&AJ Est 017?3 Phone#:_ ./ c3 579 - 6 II
Are you an employer?Check the appropriate box: Type of project(required):
1.641 son a employes with employees(full and/or part-time).* 7. ❑New construction -
2.❑I am a sole proprietor orparmership aad have no employers working for me in S. ❑Remodeling
any capacity.[No workers'comp.insurance required]
3.❑I am a homeowner doing all work myself.[No worko:rs'comp,insurance required]t 9. ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
5.❑ m I a a general contractor and i have hired the sub-contractors listed on the attached sheG. 12.❑Plumbing repairs or additions
- These subcontractms have employees and have workers'comp-insu-ancat 13.. ,[Roof repairs
6. We area right �p per MGL c 14.aOther &L-V
❑ corporation and its officers have exorcised ihaQ t of nun -
152,§I(4),and we have no employees.[No worlmo'comp.insurance required.]
*Any appliezntthat chek¢be must also rill our the section below showing their workers'compensation policy infotmation.
t Homeowners vino submit this affidavit indicating they are doing all work and then hire oxide cmmacmrs must submit a new,affidavit indicating such.
'Contractors that check this box must attached an additional sheetsbowing the name of the subcontractors and some whether or not those entities have
employe-.s. If the subcontractors haw employees.they must provide their work='comp.policy numbm.
I am an employer that isprovfdingworkers'corrrpmsaaon insurance for my employees. Below is thepo&cy'andjob site
informaton_
Insurance Company Name: �h �� �UU` �V rt nC Q Co -
Policy#or Self--ins.Lies# Y� S b v �7/ �tl L5 '"! I`I Expiration Date:
�t r
Job Site Address: s � rh:�/ �7- U n t ` City/StabP ip: 2 44 r�
Attach a copy of the workers' compens 'on policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c.15Z §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Qi`nce of Investigations of the DI?,for insurance
coverage verification.
I des hereby�r� under the pair and per �r jQer�ary that the information provided above it bw and Cored
Sitmature `ice (} p �JL � Date / I
Phone#: Sul,
fficial use only. Do notwrite in this area,to be completed by city or town o,ficiaL
ty or Town: PermittLicense# .
[[6.
suing Authority(circle one): -
Board of Health 2.Balling Department 3.City/Town Clerk 4.Electrical Inspector tit Plumbing LWector
Other
Contact Person: Phone#
Permit Services 401 246 2868 p.6
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Massachusetts - Department of Public Safety
Board of Building regulations and Standards
License: CS4)98666
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ROBERT A LABEOZ
304 BOSTON POST .00
Wayland MA 01718
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Expiration
Commissioner 05109M17
d
Permit Services 401 246 2868 p.7
OWNERAUTHORIZATION J J
Job # [ 1 7
I
TO BE COMPLETED WHEN OWNER'S AGENT OR
CONTRACTOR APPLIES FORA BUILDING PERMIT
I• '���� �' �(cc.�,«" as owner of the
subjectproperty
hereby authorize LaBelle Roofing to act on my behalf in all
matters relative to work relating to this building permit
application,and all permitted work
� 4 J
Signat re of Customer Date
(n�µ 'y 1aJ TI 't yN • '�S w` fA
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4 n J.l
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ft,4 PAr
�� a'%�%i 7�">.V%lIM1N/—Y'if//.fI 1�'� � C1rtr ! ( NAN••Jl.�
OfficB of C:ousumer Affairs & Bu'; DU,5 Rce,!Ulatillm
HOME IMPROVEMENT CONTRACTOR
if ,Registration: 154084 Type:
Expiration: 2/5/2017 Private Corporatior,
LABELLE ROOFING,`INC:
ROBERT LABELLE
'1104 BOSTON POST RD �
dlesdersecretary y'.
Permit Services 401 246 2868 P.5
1
HOME IMPROVEMENT CONTRACT
Date: / ( — Sold.Furnished and Installed by:
Job# ( i L4� LaBelle Reeling,Inc.
304 Boston Post Road,Wayland,MA 01778
Phone:508-35iL7663;Fax:509-359-7662
Federal ID8 20-8350649
MA Home Improvement Contractor Reg_#154084
I S �i/�> zy sT r� ••1�
InstalTatinn Address: Sat r-)A Gl
hrm.s wmkP`ar Clty Stem Zip
[Iwwe rkwe:
Home Addrtss: '
(if different lnstallaboa Adulaa/ Qty State Zip
Protect lnformatjoa:VWcrYoe("Purchaser),the owners of the property located at the above installzliun address,eirerlo coulrmt with
LaBelle Roofing,hie.to furnish,deliscr and arrange for the installation of all materials as described on tlx=oiled SPae Sheet J: I (C./
LaBelle Roofing,Inc reserves the right to eantel this contract if,upon re-inspection OF the job,LaBelle Roofing,Inc.determines
that it cannot perform its obligablOw due In a structural problem with the home or because work required to complete the job was
not Included in the contract.
DEPOSIT PAYMEN'r OPTIONS
(Sabiect m 6md lemicauera andha cretlil approval)
i
CONTRACFAMOUNT S 2.500- 1. .Cuhlers Check or US,bstal gem-cc Money Order
�j t!�,, (Made payahk to Lapels:Roofing,bw.)
siASS DEPOSIT S �,0Q70 2. Credit Cnrda payncat oplionaCkcic one Below
Visa MasterCard Discover American Expreu
BALANCEDUE ('G, Amt'. L.P.Doc:__
ONCONIPLETION S JJ
Nano W A oppea v on Carr!:
Indiente Payment Method Coe 'BY my/am signmere bebw,btve agree m aUor LaBCHc It ofrng Joe.to
BALANCE DUE ON COMPLETION: charge the above referenced credit card for its,deposit indicated
t1r[Il10Id.:['6 SI®IONR DyO.
Puchaser agrees that,immediately upon satistactory completion nf01e work Perclssec will execute a Completion Cerlifrcataam pap soy
balance due.Purchase aim agccs to be jointly and severally obligated and liable baeundm.
Entire AEroemcnh'ILis aglcenseaI and its nRachments,including my tinaucing agreement,con7in the complete agreemen-between the
parties and cannot be emended or modified unie-es in writing in a separate agreement signed by bothparnics.
NOTICRTOPURCHASER
Do nut alga this Contract mybefore,us,rod it.You are onBded to D Completely 6und-in CUP,of the cnniraa at the lime yea sign.X. It protect
Year rights.DC not sign y eompletina CC rilRwtc or aerecerurd sludng mar you are rallrfled with the emirs project before this projeC is
eampicte.Lase prohibit,Mmo repair cone ractor,from requesting or Accepting a Completiun Cortiocere dened by the mmur Prior to tar Aetna,
comPletbo of the mark eo he Performed came,the contract.
YOU may Cancel this transaction at coy time print to midnight afthe third busiucss day after the dam ofmis coafracL Seen Nab.of Caatehauon
for An CIPlomuan of this r%hL Ilines will In,a service charge note"to 25%of lee contrast amount B the job is cmcelW by Purchaser AFTER
the third batteries,day.
➢FhCOPYtSIGNATUREBELOW, D A(i.6 TU DF.BOUND BY THE TERAfS OF THIS CONTRACT.[,WE AC.'CNOWLEDGE RECEIPT
OF A CONTRACT
F THIS CONTRACT AND 6OMp LETM COPIES OF Mr NOTICE OF CANCELL'1TION.Do NOT SIGN THIS
CONTRACI'IP]'HERB AR' YAfsPN SPA ES.
SUBMITTED BY: Dale C1
s
ACCEPTED BY:
monowne
Date
HO:If<eM1OC1
VO'f10E:ADOITIONALTERNIS,CONDITIONS AND WARALAA 11 flei AVE STATED ON ME REVRIVUCSIDEANDARE PAN'I rIFTRtS CONTRACT.
Nbite-Of6ee Ydloa'{mlw¢r PnkSaln Cdisullao
1
North River Bay Condo Trust
15 Northey Street
Salem, MA 01970
October 8, 2015
To Whom It May Concern:
The Condo Association for North River Bay Condo Trust at 15 Northey Street, Salem, MA
01970 is aware that two of our trustees, James Regan in Unit 3 and Anne Callachan in Unit 4,
are having the skylights in their units replaced by LaBelle Roofing, Inc.
Sincerely,
ristina Kartono
Secretary for North River Bay Condo Trust