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15 NORTHEY ST - BUILDING INSPECTION cl �zT) The Commonwealth of Massachusetts W Department of Public Safety Massachusetts State Building Code(780 CMR) n Building Permit Application for any Building other than a One-or Two-Family Dwelling L 1/ ,(Phis Section For Official Use Only) Ci nit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) /.S oPJ-he ST Sotle-(A Af 0I4'70 'n No.and Street Up�� 3 City/Town Zip Code Name of Building(if applicable) UO SECTION 2 PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows*low Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit WpenJLFrI) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Q n Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ IV14 ❑ Q� Is an Independent Structural Engineering Peer Review required? Yes ❑ IS❑ '3 rn Brief Description of Proposed Work:. r c� r. cJ't tATm SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosers(See 780 CMR 34) O Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)k Area Per Floor.(sq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a Ilcable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: business ❑ E: Educational ❑ F. Facto F-I❑ F2❑ - H: Hi h Hazard H-1❑, - H-2❑ H-3 ❑ H4❑ H-5❑ 1: Institutional I-1❑ I-2❑ 1-3❑ hI❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ - S-2❑ U.. Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ !IA ❑ fill ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑' • Railroad right-of-way: Flazards to Air Navigation: i•\I listom Commiation Rcvic, Not Applicable❑-• Is Structure within airport approach areal — Is their review completed? or Consent to Budd enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code Use Group(s): Type of Construction:_ Occupant Load per Flour: Does the building contain an Sprinkler System?: _ Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION N`e and Addr ass of Property Owner 42 far\ I S iVor+:b S T Un 3 Sale rv. i�i P 019 7n Name(Print) No.and Street - City/Tosvn Zip Property Owner Contact Information: 7N- 71g. 0I 27 Title Telephone No.(business) Telephone No. (cell) e-mail address if a livable,the property owner hereby authorizes lober�- IraQejlt 304 6os �xFQa y/s la.ad rhR dt �}g N:une Street Address City/Town State - Zip to act on the property owner's 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 Comtruction Control then check hen O and ski Section 10.1 10.1 Registered Professional Res onsible for Construction Control. Name(Registrant) Telephone No. a-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - d. e, be fit Audi CS Company Name 6 6 k ob e r �- a iUz Ae D y Name of Person Responsible or Construction icense No. and Type if A plicable Dotis�Aos+ �a �4 raga �, of ,� g Street Address City own State Zip r�ar3 ism - �bL3 9)Vi- ��° g396 Telephone No. business Telephone No. cell e-mail address SECTION 11:1V0RFEK9'COAI1'ENSA IION INSUItA.NCHAFFIUAVII' M.G.L.c.152.9 25C6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide tbis affidavit will result in the denial of the issuance of the budding permit. Is it signed Affidavit submitted with this application? Yes 17 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ I. Budding $ a goo Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ - appropriate municipal factor)_$ 3.Plumbing $ d. Mechanical (HVAC) $ Note:Mininmm fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to Pr 6.Total Cost $ S-OD (contact numicipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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 o y knowledge and understanding. - Kor4 �.aG4 Dwno/ So9 3Se 7b13 Flo- ly- �� Please print anr(_,sign`�m J1D3,� �d . ./0.yl/�I� m d Telephone 7j45 Date O O Y W Vr Street Address C ly/Town State Zip Municipal Inspector to fill out this section upon application approval• Name Date \ The Commonwealth ofMassadhasetta -Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 0211 4-2 01 7 www massgov/dia. WIVarkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FII ED WITH THE PER11ff=G AUMOR=. AnplicantInformation I - Please Print L •bl NaMe(Business/Organimtion/Individual)- `/n, Lk b:{ in I . Address: J oq ���\ rfS+ RcA `J City/StatejZip: 'Met 01 7-79 Phone#: J S9 - � III Are you an employer?Check the appropriate box: Type of project(required): Luf f am a employer vrith _employees(full and/orpart-time).* 7. ❑New construction 2.❑I am a sole proprietororpartrumhip and have no employees working forme in ,$, ❑Remodeling any capacity.[No workers'comp.insurance required] 3. I am a homeowner do all work 9. ❑Demolition ❑ mg myself.(No worlaus'comp.iasur-mce required]t 4.❑I am a homeovner and will be hiring contractors to conduct all work on my property. I vri0 10❑Building addition , ensure that all contractors either have workers'compensation insurance or an sole l l.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.[�I sunhe a general contractor and I have abed h sub-e rkers'ors Tiered m n ailached shear. 13,. Roof airs - These subcontactnrs have euployees and have workers'ramp.msinance3 _.� repairs 6. We are a corporation and its a.Tiess have exercised their right of 14. Other `S(s`� ❑ exemption per jvtGL e. §1(4),aad we have no employees.[No workers'comp.insurance requned.] *Am,applicantthat checks box"]must also tat our the section below showing their wodceas'compensation policy information. r Homeowners who subadt this affidavit indicating they are doing all work and than has outside contractors;must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-conomem s;have employees,they must provide their workers'comp.policy numbs. I am an employer that is providing workers'compensadon insurance far my employees. Below fs the policy and job sue tnformation Insurance Company Name: 0L� h r� ` �vf C y�iti R © . Policy#or Self-ins.Lic.# , `0�7l /1�l8' ""/.' I Expiration Date: cc Job Site Address: I S. A/0r-4_h4 S� URr f 3 C�ty�tate/Zip: Ja �Q VV., Y1'IA ©/ 170 Attach a copy of the workers'couLpelfsation policy declaration page(showing the policy number and expiration date). Fai.Iure to secure coverage as required under MGL c.152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-yew 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 maybe,forwarded to the Once of Investigations of the DIA for instna lm coverage verification. I do hereby under thepain and pen � :irnry that the o formatfon pro ided above is truf and corrLrect Signature: t�� •� [.- G t - Date. /b/ 4 /7/ /S Phone tr Officcfal use only. Do not write w this area,to be complied by city or town official City or Town: PermittLicense# ' Issuing Authority(sit-in one): - - 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person Phone# Permit Services 4012462868 p.2 d _ HOME IMPROVEMENT CONTRACT Date: —I Sod.Furnishd and Installed by Jolt# (� `-i lJJ LaBelle Roofing,Inc. 304 Beaton Post Road,Wayland,MA 01779 Phone 509-359-7663;Fax:509-358-7662 Federal ID#20-I350649 '' II MA Home Impeaveelmeul Contactor Reg.#154084 Installation Address: 1 S �C/ "I�'�y 5+ Gt, t" 3 Se city Slue s \Vmt Pbw.- Zip Pure 1C Hottentot: '7 .11 Nome Address: (Ifdifferent fiuminsmllation Address) City State Zip Proicct Informatlim:YWa/you("Purchaser"),the awaeta Ofthepmperta'located attlic have installation address,ofTcrto oeatatt with LaBeUe Roofing,I=to ftttajsb,deliverand arrange fot the i[SwIlalioa ofall materials as dcsmbed on the snached Spec Shoct#_ f UC La3000 RooDrr&Inc.reserves the right to canal this eonimctif Upon reinspactioa of thejob,LaBelle Roofing,Inc.determines that it cannot perfanti its obligaliOm due to a structural prublem with the hove or hesause work required to enmplete,the job was not included in the eautram - •z �I7� DEPOSITPAYMENT OPTIONS �7 C9 , (�Subjett to toad wrifiraann ondtar ert&t nppruvai) CONTRACT AMOU V // L T S L 5,CZZ 1. rl m:cljlcasbtau Chwk or US Postal Stt+•icc Money Order c payalll-to L-Ballc Roofing,Inc.) of -LESS DEPUSrr Sga3U- ist- Credit Ca''d' poyment epuoas-Cncle One Ralow Vim Mnaw Ck" Dismves Americwt Exprtn BALANCE DUE V�GC aActaa. Sap.ikttc UN COMPLETION S N'nme as it appeaes on and: Indiwk Payment Method For 'By my/wr vynm a blow,Art agree to allow U&III,Roofing,Inc.to BALANCE DUE ON COMPLETION: charge the above rdrnaced ore&:"fw the deposit iralialed. Cardholders Sognawa fMN Vtot hmer agrees that,immediately upon satufictrry,mmple ir,of the work,Purchaserwiil"mum a Cwuptdimt Certificate and pay my balance duc.Pun:haser also all ents to bejointly and severally obligated and liable here aft. C•.ntire A¢reenenl:This agreement and its amichvrmts,including any fmaatir.g agreement,contain the eampka agreement between the patdea avd c I-c be amended or modified unless in nxjting in a avlarec agreement signed by both phe CO NOTICE TO PURCHASER Du ant Sign tlds Cananee before you read it Tom are matted no o mmpielely RRed-In copy of the contract at the ttmeyousiga.Keep it to proket yourrfgh0.Dv not sign any Cmpletiou Certificate or agreement abating that you are satisfied with the conm projtel before this project is eampkre.Law probilde home repair mWraelors from requesting oraecepting a Completion C*rt6"(e vga d by the owatr prior to the actual campkdcn of tae.wrk to be parformcd under the contract. Yoa My canal(hit n•na teian at any time prior to midnight of The third buaneas dry after the date of this contract See Nodce ofcmeellanion for au explaaadon of thisright.Them will be a stake charge equal to?5%the Third busleaets day. of the mvtran nmouat Hthe job it Cancelled by Purchaser AFTER BYMY/OURSIMkTUHEOP.LOWI-, A RES TO BEBOUND By THE TERMS OF THIS CONTRACE UWE ACKNO1WLEDGERECnPi OFA COPY OF THIS CONTRACTAN 'Lk' OMPLErED COPIES OF THE NOTICE OF CANCELLATION.DO NOT SIGN THIS CON1RACf IFTUERR L CS ACE& i aunt ul rEn BY: Dow s ,tit ACCEPTED BY: Doc_/ Homceagt re — xo®awna Date — NO'IICe:ADDRIONALTPJNtS,COWIT1035 A"WARRANTIES ARE STATED ONTHE REVERSE SIDK AND AIDE P.Vtx OF THIS COMMACT. whin-0tT YdlarGmramw Pta:-Sat.Cannhma Permit Services 401 246 2868 p.4 OWNER AUTHORIZATION Job# L (y E i I TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FORA BUILDING PERMIT I' J4 ~csey"^ as owner of the subject property.1 i ✓U�r� fie' 5,- 'kP 3 S{� A f) 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. Signature O Cus Omer Dat Permit Services 401 246 2868 p.6 Massachusetts - Department of Public Saf ety Y Board of Building Regulations and Standards License: CS4098666 ROBERT A LABE_)�LE , 304 BOSTON POST F f Wayland MA O1718 .r `J }rlit Expiration Commissioner 05/09/2017 t y '.•5i' r . r.rivr.'r.ay ':l'di r; !�n...�. . F• � '/7; ,., Ras�"r,PC f19�4�061516 FfitC9':?.9'9;d SP';t as: u'>;9 Se6va;:i Y�C}t',Q0981iO k5 HOME IMPROVEMENT CONTRACTOR ,'Registration: 154084 Type: Expiration: 2/5/2017 Private Corporation L.ABELLE ROOFING, INC. ROBERI' LABE..LLF 0/1 BOSON POST RID. Undersecretary ` i M V t3 fi _ �µ +Ca