4 OUTLOOK HL - BUILDING INSPECTION (2) The Commonwealth of Massachuscits
/ Town of
Board of Building Regulations and Standards
j Massachusetts State Building Code, 780 CMR. 7'"edition mallow
i. Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One- or Two-FunulY Dirrffing
This Section Fo Official Use Only
Building Permit Number. 1 4 a A Date Applied: i
Signature: ^C` 20- (c
Builddirti Commissno a to of Buildings Date
SECTION 1:SITE INFORMATION
I.1 PropertyA ddr ss: 1.2 Assessors Map& Parcel Numbers
H Grail S��u+7, Mkt
1.la 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 n) Frontage(R)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewge Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system O
Check ifyesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Orr'pf Reed: .
viuS y �laak L,.(I
Name(Print) Address for Service:
175- Ivy- X 4r,Y
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(ebeek all that apply)
New Construction 0 Existing Building 0 Owner-Occupied Repairs(s) dl Alterations) O 1 Addition 0
Demolition O Accessory Will.0 Number of Units- 01her 0 Specify:
Brief Description of P posed Work': o,� 'Joinle eA 7J:i✓`Q
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Use Only
Labor and Materials
1. Building S S D 4G 1. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
I Electrical S 0 Total Project Cost'(Item 6)x multiplier it
Plumbing S 2. Other Fees: S 07 r�
4. .Mechanical (HVAC) S List:
S Mechanical (Fire S Total All Fees: Sj
Suppression)
M1 Total Pro ect Cost S / 'j, 66 Check No, _Check Amount: Cash Amount:_
j / , ❑Paid in Full 0 Outstanding Balance Due:
s To �- ��(-A,
t�
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Suptrsisor(CSL) 7
I t Q 7
*6i ,(d E t L �� V� L,censeNumber Ecpratio Drat
N�rpe tit CSL- H IJer (( pp List CSL Type(.cc below) U
l�. �L�ePS CT I'P�T M� T. Description
A,kkesf
U Unrestricted u to 33,000 Cu. Ft.
R Restricted 1&2 FamilyDwelhn
Sgrumre N Mason Only
47$'s-31-033`a RC ResidentralRooftn Covering
Telephone W S Residential Window and Sidra
SF Residential Solid Fuel BurningAppliance Installation
D Residential Demolition
S.I�tglstered Home Improvement Contractor(HIC)
HIC Company Name or HIC Repstrant a Registration Number
aefa ) .rknMc e� � 1; M/t ot�iGo d7/rr
7Sf s31 03 c� Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.1-e. 152.J ISC(6))
Workers Compensation Insurance affidavit must be completed and submined with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed AIIWavit Attached? Yes..........Of No........... O
SECTION 7m:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S"Cl
CONTRACTOR APPLIES FOR BUILDING PERMIT
1, R _L� ( Y nr+K S , as Owner of the subject property hereby
authorize 1-6 w n_\c 1 o,ne T� orr usm e, t to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, L3 e S le y , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate,to the best of my knowledge and
behalf. WL'S ley /�eq..ds
Print Name
Signature of owner or Audionzed Agent Date
Si ned under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hues an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will nW 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 110 R6 and 110.R5, respectively.
2. When substantial work is planned,provide the information below
Total Doors area(Sq. Ft.) Iincluding 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.baihs
Tvpe of heating system Number of decks/porches
T�peof cooling system Enclosed Open
1 "Tool Protect Square Footage"may he. uh,tiluccd for 'Total Project Cost"
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CONTRACT#,.✓
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r" °�r. YiEMtZD INSTALLED..,.SALES GONTiAT g .
'rt 'INSTALLED SALES{SPECIAiLIST 11. NUMBER ^• CUSTOMER
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DATE f LOWES CONTRACTOR LICENSE NUMBER t CASHREG `
CAFO �,* }jl CHARGE JM
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MAyMD State License Number AIFOther Slates Lowes EMPtayee Number g ,. .kx 'r `w1 ',`. }'w ."ar., u x e;
AsL CT,rFL MA MD NN454SD�Onlimi[ed T,N#16066 onty,, A7?,rrt „`t � � I.
.,,This Is s co{ttract,}retween Lowe s(as defined m the Terms hand Conditions)(Lowe s)Aand the�above-named Customer fbr the installation of goods,' t the fir" ;
p,Ctistomer 5resld"entialrgmises(the Premises)aft to"stallatwlradtlress !. � ,> '' �k5 ." ; y`s Wo
V,j STREET ADDRESS. •� �'fi`• >a 1a:• T wb G',T(Y #s`A ••# •+ a F a STATE } tZIP a • T ><-x
Add�t�otial`Specrtications The Environmental Protection Agency(EPA) has requested that<.ta MaUsl; { �
,L'owe s noti int tallation customers that a lead based' eint hazard ma ,exi§t in dwefliri s built- € Tax *
fy.. P" Y 9 Jk74
priiir to1978. See pamphlet EPA 747 K 99=001 fdr detailsLab`or
4' x
}n Tax
=.41
a* R `` yy Totals s .: u� C.�1�rG ,'+u 1. 5s - tt
nt $,.Whe;e,appliceble labor is taxable
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a 'I`S" 'E° sfmiatedc ompletion'daeti's [fill oork is to commence upon:reasonable availability ofCtractodhich is anticipatedt
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NOTICE TO CUSTOMER
P ct ri Yx*o .w drdha.se,a�t i,
AII'iiems listed in this contract and speaflcahon sheet(s)`are to be installed under conditions agreed upon at time of purchase and at the"puce appearing on this •�,;,]
contract form..,This assum es,sound existing substructures superstructure and points of•attachrnents Extra labor or material Incident to.installa Ill
onnecessltated�4'r:
by defectwe substructures superstructurre,points of attachment,orthe moving of fixtures or appliances to be�billed at extra cost to customer
DO:NOT SIGN.THIS CONTRACT UNTIL COMPLETE AND YOU HAVE READ THE TERMS'4ND CONDITION%S CONTAINED ON THE
REVERSE SIDE OF THIS CON�RgCT BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ ;UNDER
t STANDjAND)AGREE TOE THE-ZERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF T1.H CONTRAC IS T YOU ARE
r EN ITLED TO A COPY`OF THIS CONTRACT;ATtTHE TIME OF SIGNATURE zT, :11
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' e WITNESS OUR HANDS)ANDrWAL(S)BELOW THIS i W DAY OFi dC -+- x s 'rctyC,, ` •'t+"ur r,: x A�u t't„•strt"^g;
xi
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Speaallst or Above *'Spouse
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4 ). CuSt�r�rier acl5n`owiedge's receipt of a Prue cor. 1�of>tFiis contract which avaslcomplefety tilted in poor`'t8°CUstomen°stexecutrbn,h egf 1t.credd rs
x.
extended to yqu you the buyer may cancel this tradsachon at any hme prior,to midnigtit,of the third husmess„dayatter tf)e da cif thrs t ansaction. '
iSee tFie attachetf.no ceof oancellation form tov an expianabonofthis $x:, A� �' �," e :•�
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Work is to commence upon reasonable avadabtlity of Contractor which is anticipated to be t c.a [fill m date]
stimated oro letion date"ts"�""" stt:2 b . ;- +• s•.n�.' '„rosa +.,r.,;%.w.za.:3x.. c.; ,:aex+,. `ia,. t+;, :. w "p [fdl in date].-'
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NOTICE TO
y R a.a y°r._h. r,d at th-6 Pr 'e a t 6@4
�Aii.,items listedin this contract and specification sheets)are to be installed under condrtions.agreed upon at hme of purchase and at the pace appearing on this ' �F
7. ;contract foim,;This assumes sound existing substructures;superstructure and points of attachments: Extra tabor or mitsrial incident to',installation n_ecessitated ,
` bydefective substructures,superstructure'pomts,of attachment,or the moving.of fixtures,or appliances to be billed at extra cost.to customer. ., �'' "" '
DONOTSIGNTHISCONTRACTUNTILEOMPLETEA14D YOU HAVE READ THE TERMSANDCONDITIONSCONTAINEDONTHE: '.g
REVERSE SIDE OF THIS CONTRACT. BV SIGNING BELOW,YOU AREACKNOWLE®LING THAT YOU.HAVE READ, UNDER-,i
STAND AND AGREE TO THE TERMS AND.CONDITIONS SET FORTH ON THE:REVERSE SIDE OF PHIS CONTRACT.YOU ARE
ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME AF SIGNATURE.
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WITNESS OUR,HAND(S)ANDS AL(S)BELOW TMIS § t(D DAY OF {' Cr�t,�jt�- -- .a D x
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[ -. -✓Owner,
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Specialist or Above
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extended to you'you the buyer may cancel this transaction atany bme print tomitlmght of 4he Third busines@itay affer the hate o(thistransacRon :-
iSeet hie attac rfou oFbncellatwn form for ar]'explanatron,of this right; ,g Str, .�'f;�''y "E t t a ' 9 3 .,:
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FROM :RONCO CONSTRUCTION FAX NO. :19785323341 Jul. 15 2009 10:24AM P3
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The Coinre0 weafth of Massachusetts
Deparnttentoflndus&WAccidents -
Stt t # Offl;a oflnVestgahons
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600 WashaWon Shwt
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W".Mass g`ov/(fia
V. s Workers'Compensation Insurance Affidavit:Builders/Contractors/Efectriciati2sJpltthe
licautlnfor'maLon i
' s Prase Print L
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p s '�N2ntC(Business/OtganrzationQrtdwidual): /� c.O. f6+JS Tit t)CI )tG /QiJsts,fL� CvWGH��c.) � .-;� ..
aaarega:�a Tpv� )eeres: e. 7
Ctty/StatelZip M)f oo7dI phone#: !� 'l�- S 3 � -0 a ,
st. Are yw an employer°Check the appropriate box: t '.
' r I' ❑ I am a employer wit h a 4 - :. `pe of project(requh'ed):
❑I am'a general contractor soil I,' 6. El Nev c6osinCtion 'g,
�,s e � � 1 employees(full andior,part tmre)'� have hvedthe anh-contractors
am a sole proprietor or partner listed'on the attached sheet t 7. ❑Remodeling '
k smP and`have no employees These sub-contractor's have 8. Q Demolition
t.
For me m any capacity. -workers'comp mitnance. - 9, Budding addition:
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[No workers comp,'ia_sdt ce "5. E We are a coaTkIm on and its g
,, n ie,9ed'7 officers have exercised their 10.❑Electrical repairs or additi ra y
' 0 7 am a homeowner doing all work tight of exemptionper MOL I1.0 Plumbin re �. '
�� WvselL[No workers comp a 152,00),and we have no, 8 Pans or addm ns
rnsmance regvued]t e�,loyees.j1Vo workers 2 Roorepaits 4- __.:
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8 , ,; _ comp:insurance tequired.l
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x 3 tMXtapp'hwat Nat checks boxifi must a4so fill on the section Dgaw slgwingthen—*. comP�tionPulcY
x Homeowaets who aubnutNrs atfidav,t tvdttatmg NeS'atedoing ill work and tken hireoutsidecaonaeintamusl submits mtv aSWatitntdicatiilq snch
Nb� a CanvacNrs Poaz ejieck thtsboz mucr:a[tacled anadoe*shsetsho Mhg the mmeofthesubcennactoa and thvrworke[s'watp.policy mfolmasm
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;`' { � Insurance Company Name �` �, 1.
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;� ' ]Nh #or Setf,ms _ s
Expiration Date:
r �Iob Sate Address a. +
7-77
Ctty/State2ip: {;.
' Attach a copy of the workers compepsation policy declaration page.(showmg the policy essmbei and expiratioe )
F' hire fo secure cov .eQ :. r
erage as r cored under Section 2SA of MGI c.752 can lead to fihe' ro f
fine up to$1 500 00 and/or orie- ear s- P rn�osrtion of cruninal nalties o a
Y nnpns Be ado,as well as crvrl enalties m the form of a S1n7?4VORIC ORDER and a�fine
. up-' $2S0 0' a day against'-the violator.'Be advised that a copyof this statement t'
Imeshgatio�`of the DIA for,-insurance coverage verification. m f°nvarded t°the Office of
t do hereby cernjy under the pains and pereolnes ofperfury that the raW—noa provided above is true and correct.
r
e SRti Date
OfJfcial useonry DoAPaiwite in this area,to be eo feted_ ?M by ciry or town-TIda; -.
Cdy or T0,,... z Permit/License# E
'Issurn Authority,g (crrela orre)
1 Board of Hearth 2 Bwldng;Department 3 City%I'asru Clerk 4.Electrical Inspector 5.Plumbing Inspector
;6 Other
" '.ConWMI'eson
- Phone#: I
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FROM. :RONCO CONSTRUCTION FAX NO. :19785323341 Apr. 08 2010 09:33AM P1
10-99-09; 19. �.$ ;patrick-J-woods-insurence 99785323341 ;9785318h17 # t/ 1
PRODUCER THIS ClRTIPIRAT!IA ISSUED AS A NATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Woods P J Inmffmmm ApentV Ina HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
h emm ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
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COMPANIIIIIIS AFF60110 INSURANCE
COMPANY A GRANITE STATE INSURANCE COMPANY
INSURED --
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THIS E TO CERTIFY THAT THE POLWAEB OF INBLRANOE Uff=BELOW PAVE BEEN ISSUED TO THE N uml;NAMED ADM FOR
THY POLICY PWWD INDICATED,NOT WD'HE'TANDIND ANY REQIAREMENT,TOM OR COMMTION OF ANY CONTRACT OR OTHER
CQOW"WITH I188PP.CT TO WyHrH THIS OERfINCATE MAY BE 188UED OR MAY PEIRAW THE INDURANCB AFFORDW THE
POLICIN DEM10120 HYREIN IY BLEJECT TO AU.THE TMIW,EXGLUMONS AND MOM" MM POUCift.LmT8 BHWTN
MAY HAVE UN N11OVOW BY PNOOLAND.
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` -- DEPARTMENT
.M .14 _ 120 W.%AII\G:ON St'NLET•SAI I:\1,tit.Ni.It i It it I i
'1'FI:978.7J 9595 F%x:978-744'/tla6..
3
Construction Debris Disposal Affidavit
h (required Abr all demolition and renovation work)
In accord utcc with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40,S 54;
A Building Permit li is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
S 150A.
The debris will be transported by:
(narne of hauler)
fhe debris will be disposed of
(name of aci ity)
laddrexs of facility) - -
signature of permit applicant -
date .�
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