6 OUTLOOK HL - BUILDING INSPECTION -� 46 Ci�-`+ (- -2-
The Commonwealth of Massachusetts }?
�A Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR S�A(Ly�EM
�zr3f S W 12011
Building Permit Application To Construct, Repair, Renovate Or DN11nIALal 11
n One-or Two-Family Dwelling
u I This Section For Official Use Only
�O Building Permit Number: Date Applied:
t� Building Official(Print Name) Signature Date
SECTION I SITE INFORMATION ' = •�F
1.1 Proper ddr s: 1.2 Assessors Map & Parcel Numbers
ox
1.la Is this an accepted stree . 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(ft)
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? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 I(I VA �
Name(Print) ^^ City,State,
''W
B o ((JJ
No.and Street O�
Tel Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units J Other ❑ Specify:
Brief Description of Proposed Work 2: -4 i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official b
Labor and Materials tal Use my
1. Building $ 1. Building.Permit Fee: $ Indicate how fee is determined:'
1-1 Standard City/Town Application Fee '
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ _
4. Mechanical (BVAC) $ List: .
5. Mechanical (Fire $
Suppression) Total All Fees: $
(� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ J ❑Paid in Full ❑ Outstanding Balance Due:
SECTION5: CONSTRUCTION SERVICES
5.1 onstruction Supervi r License(CSL)
l^ /� 110100-7 la Joa)
T C7✓�V 1 License Number Expi tag' ion D2te
Name of CSL Holder
`463 sl List CSL Type(see below)
No. and Street Type Description _
C �M n O 1—Z�� U Unrestricted(Buildings2 Fam u el ing cu. ft.)
City/Town, Stat . IP '' V ,j'` `T R Restricted I&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone, Email address D Demolition
5.2 g egistered Home Improvement Contractor(HIC)
Hl Registration Number x ira w ate
Hl!q Company Name or HIC extra e
and Street , Email address
City/Town, State,ZW 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 Issuan c of the building permit.
Signed Affidavit Attached? Yes .......... No ........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT,
1,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
— 5e, eok4 6
Print Owner's Name(Electronic 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.
/Fo.-,,._/C Iyo 70 /3
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 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.eov/o Information on the Construction Supervisor License can be found at www.mass.Pov/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"
CITY OF S.U.F.M, N'LkSSACHUSETTS
BUILDING DEPARTMENT
` 120 WASHINGTON STREET, 310 FLOOR
o TEL. (978) 745-9595
FA.x.(978) 740-9846
ICI\iBERLEY DRISCOLL
MAYOR THOMAS ST.PtERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSL%IISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(nanjUlfhauler
The debris will be disposed of in :
(nam"f facility)
(address of facility)
signature of permit applicant
date
dcbriv17.diic
CITY OF S.ULEM, TMASSACHUSETTS
' BUILDING DEPARTNSENT
120 WASHINGTON STREET,Y°FLOOR
TE1_ (978) 745-959S
FA.Y(978)740-98"
KISiBERI.EY DRISCOLL
MAYOR T HObW STYIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO.%MISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PlumberS
Applicant Information Please Print Legibly
/
NaMe(BusinessiOrganizattionvindividual)/ C
Address:
City/State/Zip. 1 Yn Ol g Phone #:--(S 3 YX 73
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet 7. ❑ Remodeling
ship and have no employees Th sub-contractors have li. ❑ Demolition
working for me in any capacity, orkc comp.insurance. 9, ❑Building addition
[No workers'comp. insurance 5. We are a corporation and its 10.[,] Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12 ❑ Roof repairs
insurance required.]r employees. No workers'
9 ] I
comp. insurance required.] 13.0 other
-
Any applicant that checks box#1 most also 611 out the section below showing their workers'o,mW,,,jon policy information.
t I hVreMonst:who submit this affidavit indicating they arc doing all work and then hire outside commemn must submit a now,andavit initiating such.
'Conir:snon that chick this lox moat anactod an additiurai shcet showing the name o!the alb eommctms and their workers'canp.polity infomation.
I am an employer that is providln workers' otnpensat on Insaran a for my employees. Below Is the policy and fob site
information
Insurance Company Name:` _` p, /'�
Policy#or Self-ins.Lic.#: l[V C V),�U�..,`�. J �y�� Expiration Date
Job Site Address: L C����t l ILL City/State/Zip:SotA
Attach a copy of the works"'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under theibins and penahies of perfary that the information provided a ovve is true and correct.
Sienat ire; ��v�C.7�)(��l� (� y�p Date
Phone#: csce )_3 L V `13 -I
Ofjirial use only. Do not write in this area,to be completed by city or town offlciaL
City or Town: PermitiLleense#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person:.
_, Phone#:
_ r
H&R ROOFING AIND SIDPiG C --.
CALL: 508-348-4348 \j ,.q fi�l
I PROPOSALS
FREE ESTIMATES•FiLLY INSURED - - -
SHEETtf
ONLY
w"MMtCA 22 Years of Woriunarship with references MA LICENSE 9152206
All work 100%guaranteed in writing RI LICENSE ft28442 DATE�! 36
PROPOSAL SUBMITTED TO: WORK TO BE SUBMITTED AT:
NAME: kADDRESS:
Gkc A.-KJ
ADDRESS:
PHONE: ARCHITECT:
H&R ROOFING AND SIDING CONTRACTORS
We hereby bruit specifications and estimates for ROOFING COMMENT.'
1. use and shrubs with tarpaulins for their protection.
2. Stri existing roofing up to 2 Layers(Extra-$50.00 per layer par SO.FT.over layers).
S. I loose roof boards.
4. Replace all rotten mot boards up to 50 sq.f.no charge.$5.00 per sq.ft.thereafter.
5. lsfall - feet ice and water shield at all gutter edges,valleys and y.
6. nstall aluminium drip edges to all edges" ' color ite CSilver 0 Brown Ft.
7.tilrrsfatl �0 lb.fen undedayment. LCS� ! ��t1 " CtuI1. S
8. flash dormers and wall areas'rf any as necessary. S'•-(C�,l+� e.t e
9. �ve all valley If any.
10. 4--install new roof flanges on vent pipes. L
11.1-4netall new roof shingles to an roots on ARCH 3TAB cob sq. ❑ Porch Roofs
-.._- _
12. [il�nsiall new alurrunumt chimney step flashin .
13. 9stall new ridge vent to all peaks.
14. 'Cign all gutters.
15. f needs plywood after stripping rood it will be an extra charge at fair et price.
16. OPTIONS: ❑Flat rubber roof [I Soffit vents ew lead chimney flashing ❑Chimney rebuilt umpster
and Extras: ❑Garage ❑Hurricane nailing ❑Skylight - ❑Fascia or soffit replacement ❑Gutters
❑Bay roofs ❑CDX plywood ❑Low slope ❑Material supplied by customer
All checks payable to H&R ROOFING SIDING CONTRACTORS-All dates are contingent upon adverse weather.
we take ro respmsm3iyfor du and derma m yaa amc.Pleaw c°`Qrandfor remove wia . Respectfully Submitted H&R . ROOFING AND SIDfNG CONTRACTORS
Mamie cbmtg;tor nags Ai delata to ba removed,FWIy acmrsed arM'etsraed.111 wpk nananad br
2.5 to 30 years 1[ar maY agmenrem i i tms bero skptad by a pally thereto at a pace oarerthan
an address d ue.seser,whidr may pe nt ma'vi af&s.Ma"ded Ya notify th seam en�9 at h's men Per H&R ROOFING AND SIDING CONTRACTOAS
office M ardmery marl wstad.pY�egram sera,m by�6very rot Wer Man m�iprt d rite shed
business day bYoweg�Me�jnhg°t mis a hem- NOTE-This proposal may be withdrawn by ra M not accepted Wilton 15 days.
TOTAL 4' ` C)
YOU HAVE 72 HOURS TO CANCEL THIS PROPOSAL AFTER 72 HOURS,DEPOSIT IS NON-REFUNDABLE.
Payment Plan �L Date' z-3D^SIC- Acceptance of Proposal
1/3 Deposit % a The above prices,specifications, ltions are satisfactory and are hereby accepted.You are
?? S authorized to do the work as P - e It be made as outlined above.
1/3 Start '7 J c
/ Customer Sig
1/3 Completion
NO PERSONAL CHECKS Salesman Signature !"t....
Page 2
Work to include:
r
Strip existing roof down to decking
Nail down any loose boards
Install WR Grace ice and water up 6 feet
Using customers I roll of storm guard and H&R provides another roll do another 3 feet to
make 9 feet all together of ice and water shield
Install 8 inch drip edge to all edges
Repair any rotted wood up to 50 sq feet of decking , $60.00 per sheet of plywood thereafter
Install GAF starter shingles to eaves.
Install, 16 square New Gaf architectural shingles ( 50 year warranty) using the color Pewter Gray
Install ridge vent along ridges with new Gaf ridge cap
Install new lead flashing to the chimney
Clean all gutters
Included: pulling the necessary permits,
dumpster, removal and disposal of all trash related to the work on the roof,
magnet ground screening for nails and clean up of all debris.
NOT Included: Finding problems other than what is stated above that need addressing, we will notify
Nick Vakz should this occur.
r
-r`•��asior�rr;rN;
-- r'//reruroxev��rerrlf�< - motion
offim of Consumer Affairs&$na ess%ega
ME{AAPROVEMENT CONTRACTOR Type:
eg6gration: 152206 OSA
t-g piration: 818=16
H&R ROOFING
RONALDO SOLANO .. o
763 WAVERLY ST L}ndersecretarc
FRAMI NGHAM MA 01702
i