31 RAVENNA AVE - BUILDING INSPECTION id
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Board of Bytldmg Regtiluupns and Standards
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r,KSECT(OPF 6WORI{ERS'COh2PENSA17ONINSU1Nt EIDe�V[T(M G'L cz152 §2SC(6)j v
WoikeisCompnsIIUoii tes trence hffid�uet mustSbe eampfeted,ond sd6mitted with this uppticnimn`�,Ful�uie tip pn>ylde >
thts ""MR!WIII resultln the demal5of thellssu_once of�hcjbmEding:permit ,+,r`L w F t r
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" k"SEGTIONg t OWNERAUTHORIZA IgON TO BE"COMPi E ®,WEiEN^
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r FjOWNERBAGENiOIECNTRACTORAPPLIESFORBiJILI)INGPERMi9 4 rZP5f
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as Owner of the su ject ropert hereb . a
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[o heron mylbehalf Cn JII matrers � �:.
relIIuve to'�warkmnthorized by this-6ai[dmgtpermlt npphcatlon. v �-, ', + - . „ , ,� - '�;,y Ir'��i 'r'i>•'`x ' t
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°t ticT'rN I BEGTION'7be OYVNER�OR AUTHORIZED`AGEN f1ECIuYRp'TION;{y< <-�rt' `
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r asOwneror,AuthorSzedrAgenCherebyde�lare, ,
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., :thaathe-starements nndinformntion on the fo{regoing nppliwnon ore true and nceiurnte�to the best of my knowledge and+
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Pnt1bN0[,)N.GL7'- r'-yJ/y'�'v v$ :h -s• f h MEN
„ t Signature of tlwuer of Autlto.. W Age. a r '^.,t, ,
s s ..!' dr<..,. c 'Y `r'i.t a%*� i. ? } ?,Ly,ryc L[e y .�': i
(Si" edunderthe mnsmd Wtfesof ru �1 eFzh� t «r. } Pa-,.
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I°�C ?An Over»vho abteinsla buddthg permd to do"hulllter own workt''of anpwner who hires ten unreglsf ere d wntnci;tor
+t'4i_ i�i3.iue{f4iE}:3, a,5 .._;rr}a .w r.:vc E 'X c _••i 'S>=c.h.�`e..s. 'rf t-.em. fw. xF,✓:t tt -Y -Zc '.F, y
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sa f kNA,ti+lY ' Gi"�AIIt'C. x w —T�»"G!vS x 5, etr"c1� 1 `ha
-1 1 ' pragm�m o` gun�tanfrnd nderItLO L'ci 1d2A Oenmportant tnfdrmntlaii,an thekHIC Frogr$m ands 5K
f it u ConsiructmnSupeyvtsorlslcens,itg{ f c n tie ound n£7g0-CWfQd" gulgtfiins l 10 R6 and 110 R5 especitvel
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23+I When i dlZbstnnual-workus p[oniied,provide the mforma"Iion below
-' s 3M '� q )' t '' u i 'fmcludtn ggerage,timshed basemetlatics decn .sry ur�,YNhl-
=
s Ni�mberofht�treplcw wsY, m .✓- Num6erafbedrenms �- '. P' 9
1Vumber at bnthms y $ 5 s Number bfhuif%bLths�4 '" K
YP 8 Y 4 ,� t NiimbereYtietkal�nn.hes: _ � 't
3 h%t`tnlProjectSquareFootage^ finny beslibsututdTdfar "totniepro�eciCast h° ` r h
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CITY OF &UXTNI, NLkSSACHUSETTS
BUUMLNG DEPARTJI'ENT
' 120 W.1,SHINGTON STREET, 3"FLOOR
TEI_ (978) 745-9595
FAX(978) 740-9846
KINIBER�JAYORL.EY DRISCOLL
IN T'HOIstAS ST.PiERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING COM!%IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Vatt7e(Business.`OrganiiatfoNlndividual): EeAe jZ,61 ' C'
Address: ?'y� �31 /os�C_a n
City/State/Zip: /u 't 1011 dl779 Phone #: S09 3Sg ` XX 3
Are you as employer?Check the appropriate Type of project(required):
L❑ I am a employer with 4. I am a general contractor and 1 6. El 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.t Z ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. Building addition
[No workers'comp. insurance 5. We are a corporation and its
required,] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.1-1 umbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12. Roof repairs
insurance required.]t employees.[No workers' 13.[1 Other-a"tP F Re t'o-otG
comp. insurance required.]
•Any aPPlicam that ch=ks box Nl most also till out the section below showing their wwk='compensation policy information.
t I fameuwners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new,affidavit indicating such.
=Commvton that check this box most attached an additional AM showing the time of the sub-contractors and their workers'comp.policy information.
l am an employer that is providing workers'compensation insurancefor my employees. Below is the policy andlab site
itnformatiolL
Insurance Com an Name: 1�S Cv, lJi /� F/a-fC/ Ltr/'�c�r/y o✓CP'
Company
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 3/ Q' '�e"nr<` / e �t1�L„ City/State/Zip: Jn`/e, m l-- ,11/q 70
,mach a copy of the workers'compensation Polley 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
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 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.
/du herrby cer rider the
pains and penalties of perjury that the information provided above is true andcorrect
Sirnanue: Date!
Phone#: S-0 S 3-9-9 7 eKD -?
Official use only. Do not write in this urea,to be completed by city or town meld
City or Town: Permit/License# _
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phane#:
CITY OF S. .ENL I, TN'LA sSACI-IUSETTS
BUILDL\G DEPARTMENT
130 WASHLNGTON STREET, 320 FLOOR
TEI_ (978) 745-9595
FA.r(978) 740-9846
IC1�tgERI.EY DRISCOLL
MAYOR T HohtAs ST.PIERas
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSSIONER
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:
err y �3o-a r. $oa - 338 3$6
(name of hauler)
The debris will be disposed of in
(name of facility)
�4, f-
address of facility)
signature of permit applicant
►7 - v �
date
dcbrisalTdQC
. r
92.
Board of Building_Reguietio s_eadfltauda[da
HOME IMPROVEMENT CONTRACTOR
Registro� A. ,154084
E /2009 Tr# 268944 i
F P ivate Corporation
LABELLE ROOFY
1
ROBERT LABELLjE'�
304 BOSTON POShRp+,,, -
- ' WAYLAND;MA 01778 � - Administrator
' 1
f
i ✓/e �ammon: ealr/i o�./�tQaaaa/uy
poard-of BuildiggRegulations and Standards .
IConstruction Supervisor License -
Lice CS 98666
I \
E.1- /2011 Trq 98666
rt
Eli
u�9
ROBERT LABELLE�� E'f rJ
304 BOSTON PO STY.,
WAYLAND,MA01778 -'"' Commissioner- -
A HOME IMPROVEMENT CONTRACT
Date: U Sold,Furnished and Installed by:
LaBelle Roofing,Inc.
Job# " (_ 214 North Main Street, Suite 201 Natick,MA 01760
Phone: 508-647-4035;Fax: 508-647-4036
Federal ID#20-8350649
MA Home Improvement Contractor Reg.#154084
3 l `Installation Address: ✓ ¢ rI n ex r CL t o _f`V1 in ti— oil 7 d
�
City State Zip
Purchasers Work Phone: Home Phone:
e �7
e i� � ( ) ( ) ?
Home Address:
(If different from Installation Address) City State Zip
Project Information:I/We/You("Purchaser"),the owners of the property located at the above installation address,offer to contrayt�wjt
LaBelle Roofing,Inc.to furnish,deliver and arrange for the installation of all materials as described on the attached Spec Sheet#.!/S f
LaBelle Roofing,Inc.reserves the right to cancel this contract if,upon re-inspection of the job,LaBelle Roofing,Inc.determines
that it cannot perform its obligations due to a structural problem with the home or because work required to complete the job was
not included in the contract.
DEPOSIT PAYMENT OPTIONS
d- ,(S 'ect to fund verification and/or credit approval)
CONTRACT AMOUNT $
1. Check,C shiers Check or US Postal Service Money Order
/� /f! (Mad ayable to LaBelle Roofing,Inc.)
9r *LESS DEPOSIT 2. Credit Card* payment options-Circle One Below
Visa MasterCard Discover American Express
BALANCE DUE L'�� Acct#. Exp.Date:
ON COMPLETION $ O
Name as it appears on card:
Indicate Payment Method For *By my/our signature below,I/we agree to allow LaBelle Roofing,Inc.to
BALANCE DUE ON COMPLETION: charge the above referenced credit cud for the deposit indicated.
CCardholder's Signature Date
Purchaser agrees that,immediately upon satisfactory completion of the work,Purchaser will execute a Completion Certificate and pay any
balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Entire Agreement:This agreement and its attachments,including any financing agreement,contain the complete agreement between the
parties and cannot be amended or mollified unless in writing in a separate agreement signed by both parties.
NOTICE TO PURCHASER
Do not sign this contract before you read it.You are entitled to a completely filled-in copy of the contract at the time you sign.Keep it to protect
your rights.Do not sign any completion Certificate or agreement stating that you are satisfied with the entire project before this project is
complete.Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to the actual
completion of the work to be performed under the contract.
You may cancel this transaction at any time prior to midnight of the third business day after the date of this contract.See Notice of Cancellation
for an explanation of this right.There will be a service charge equal to 25%of the contract amount if the job is cancelled by Purchaser AFTER
the third business day.
BY MY/OUR SIGNATURE BELOW,VINE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT.I/WE ACKNOWLEDGE RECEIPT
OF A COPY OF THIS NTRACT TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION.DO NOT SIGN THIS
CONTRACT] THI ARE A TNK SPACES. /
SUBMITTED BY: Date )
77 Sales Consultant
ACCEPTED BY: O_� �1� C Date !p o d 1
Homeowner -
Date
Homeowner
NOTICE:ADDITIONAL TERMS,CONDITIONS AND WARRANTIES ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT.
White-Office Yellow-Customer Pink-Sales Consultant