2 RAYMOND AVE - BUILDING INSPECTION IThe Commonwealth of Massachusetts
n Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7`'edition e.,OF SALEM
J Revised January
Building Permit Application To Construct, Repair, Renovate O Demolish a 1, 2008
One- or Two-Family Dwelling
This Sectio o Official Use-Glily
Building Permit Number: 9 1 Oate Ap d:
Signature:
Building Commissioner/Ins ctor of Bu' Date f
SECTIO : SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
z .Tmcnc� Ave-
Lla 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 ft) Frontage(ft)
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,§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 Owner'of Recor
AU A <Ql 2 n roo, e
Name(Print) Address for ervice:
178-7V 8 Y6 V
Signature Telephone ' _
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': LeVyictAA— I rp ekeL,-f-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ Z U $Q L 1 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa (Item 6)x multiplier < 'x
3.Plumbing $ 2. Other Fees: $ 1 ,
4.Mechanical (HVAC) $ List: ► \ / /��_
5. Mechanical (Fire $
Su ression Total All Fees: $
q Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 2 l y S�.(, I 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) P� 2I Q3 p 3 !(
t (chae( DMilk License Number Expiration ate
Name of CSL-Holder
,5 ,ylA a�7b List CSL Type(see below)
iuA-
=RCResidential
Description
d u to 35,000 Cu.Ft.
Signature &2 Famil Dwelli-
e t� nl
9 7$-7 Roof- C--
Telephone Window and Siding
SF Residential Solid Fuel BurningAppliance Installation
D Residential Demolition
5.2Wegjste rd CName
Horne 1p{@rovement Contractor(HIC) ) b 2-72 2
HI! Com many Nam6eLor/HII/Cr eegptrant Nam � y O Registration Number e
Ad I Ir
Expi ti n Date
Sig-a m 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No ........... ❑
SECTION 7a: OWNER AUTHORIZATtON TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 1 Q�` as Owner of the subject property hereby
authorize �i ypa I to act on my behalf, in all matters
relative to work authorized by this building permit application.
„ 1a J a - !z zb14
Si a of Owner Date
SECTION y7�b:OWNER' OR AUTHORIZED AGENT DECLARATION
1, NA,w .l �}e��l�kP ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my,knowledge and
behalf.
NllavA^uel
Print £6
K
Signa re o caner o- r t(u onzed Agent Dale I
(Signed under the pains and penalties ofperjury)
NOTES:
1. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 1 IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
The Commonwealth of:Ylassachuselts
Department of Industrial Accidents
Office of Investigations
600 lfashi»gton Street
Boston, AIA 02111
www.mass.gor/din
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibiv
Nnine (Busincssorganizationilndividual): (C!"Ae D4-J_..
Address:...`' �..i. 11 � fC�Er. - - -----
I V' Gl U Phone>;`: t 7V_ � �' t CityiState/Lip:--_-�_1 _-- -....J_7 - 5 --Are you an employer'.'Check the appropriate box: Type of project(required):
1 ❑ I am a employer+with 4. ❑ I am if general contractor and 1 G. ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors
1
1 am a sole proprietor or partner-
listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees 'these sub-contractor have g. ❑ Demolition
workine for me in any ca atit\' employees and have workers'
P 9. ❑ Building addition
INo workers' comp. insurance comp.❑ e are a corporation insurances,
required. 5. W oration and its 10.❑ Electrical repairs or additions
officer have exercised their I L Plumbing repairs or additions
;.❑ 1 am a homeowner doing all work _ I�
my ell: No workers cunt right of exemption per MGI. P� P� 12.E] Rool re airs
insurance required.1 ' c. 152.§1(4)•and%No have no
employees.[No workers' 13.❑ Other__
comp. insurance required.]
'Am aprfcam that ehc&,Mr+=1 must ahn fill out tlrc,o:tion bdoe shoeing their+cnrkers atmpcasation pudic)informution.
lionteomwer oho submit this;diid;mh indicating they arc doing all cork and then hire outside contrectan must submit a nco al lidaeit indicatim_such.
=o,n:ramu that check thF bu,moa attached an addlnonll sheet ehnwing the name of the suh-:nn:ractors;cod stave xomber or not those entities hall
cmplocc s. If fife sub-eontmcufrm Itacc entpinyee..Ihc) must provide their workers comp.policy number.
I am an empinrer drat is praviding worAer.''compensation insurance for n(v emploreesL Below is the polcy and job site
infiannatiott.
T (�
Insurance Compam Nantc' >7?y1y1[l __[ � ... /J
Polio. 'or Sclf=cos. Lic.�: ���( .� ��—p� —__ Iypiration Date:_4__
.lob She Address: 2• trill RVrI------------_._..-------City/stateilip:_S,,_s 2_✓U eq 70
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25 A of MG1.c. 152 can lead to the imposition of criminal penalties of a
tine 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. 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 hereht•certift•undey th 9dpimalfies of perjun•that the information provided above is true and correct.
2 � zi it
Signature: Y' 3% '�.'`' _ Date: _�_
^ r
Phone 4: H' - '`�
Of
ri ial use ont Do not write in this area,to be completed br ci(r or town official
City or Town: Permit/License 4
Issuing Authority (circle one):
t.Board of Health 2. Building(Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.(Other
Contact Person: Phone q:
License: CS 82.193
P-sinctedto: 00
MICHAELT DEMILILE-
5 BRISTOL ST
SALEM, MA 01970
10512DII
Board of Building Regulation;and Standards
ROME IMPROVEMENT CONTRACTOR
hewswion:
.,162722
E)Oirzk90n: 416J011 Trg. 282586
Type: 'Indtvidual
MICHAEL THOMAS DEMILLE.
.MICHAEL DEMILLE
5 BRISTOL ST
SALEM.MA 01970 Administrator _a-..
a �
ACORD CERTIFICATE OF LIABILITY INSURANCEPIROUCER --
1o/2ti/zo1d,
THUS CERTMOATEm ISSUED AS A MATTER OF INFORMAIGON17
PARENTS INSURANCS AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CEKnFMTE
94 L4HN STREET HOLDER THIS CERTIFICATE ODES NOT AMEND, EXTENOR. OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES SELOVK
PRASM, MA 02960
INSURERSAFFORDING COVERAGE NAIC0
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MIRE DEKlITE db8 MD CONSTRUCTION I�IRFR a: MORTSLAND INSORAN@ CO.
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5 ]3RI3TOy ROAD,
INSIRieRa
BAL�F MA 01970
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COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOIWnIWANDING
ANY RXQURTEMENF. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUSIECf TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OFxSUCH
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STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK- INT/EXT/PATIO
DOOR
LOWE'S OF DANVERS, MA STORE# 1094 STORE PHONE: (978)646-9099
left 153 ANDOVER STREET SALESPERSON: EDWIN VELAZQUEZ
DANVERS, MA 01923 SALESPERSON ID:794346
Document Print Date : 02/12/2011
This is only a Quote for the merchandise and services printed below. This becomes an agreement upon payment and
an endorsement by a Lowe's register validation. Upon such payment and endorsement, the entire agreement, including
the specifically completed pages of this document, the Terms and Conditions included with this document and any other
addenda or attachments hereto, shall be referred to herein as this "Contract."
PLEASE READ THIS ENTIRE DOCUMENT INCLUDING THE "TERMS AND CONDITIONS." BEFORE SIGNING.
Lowe's Registration or Contractor License Number/Lowe's Contractor Name
Lowe's Home Centers, Inc.'s MA HIC NO.: 148688 Lowe's Home Centers, Inc.'s FEIN:
56-0748358
Customer Name Home Phone
S DAVID KELLY 978-744-8464
® Customer Address Other Phone
2 RAYMOND AVE 978-884-8535
L City State/Province Zip/Postal Code
D SALEM MA 01970
Installation Address
T 2 RAYMOND AVE
Installation City Installation State/Province Installation Zip/Postal
®
Code
SALEM MA 01970
MERCHANDISE AND INSTALLATION SUMMARY
MERCHANDISE SUMMARY
1161 : 1161 : STK : 1X8X8' SELECT PINE : 1 X8X8' SELECT PINE : PRECISION LUMBER - QTY 1
7001 : 24SCP.96 : STK : 2X4X96" TOP CHOICE STUD : 2X4X96" TOP CHOICE STUD : CANFOR WOOD PRODUCTS MARKETING - OTY 2
131207 : 131207 : STK : 1 X8X16 PRIMED FINGER JOINT : 1 X8X16 PRIMED FINGER JOINT : IRVING-FOREST PRODUCTS (MAINE) - QTY 2
106126 : 6000C : SOS : SOS PELLA STORM/SCREEN DOORS: SINGLE STORM DOOR FULLVIEW STORM : CLO LARSON MANUFACTURING COMPA -
QTY 1
Store 1094 Project No. 317653137 for DAVID KELLY Page 1 of 8
STORE COPY
231061 : NA : SOS : SOS ATRIUM VINYL PATIO DOORS : 336 SIDELIGHT(20 3/4" W X 80" H) : ATRIUM WINDOWS - QTY 1
326800 : PRODUCTCODE : SOS : SOS RB PNT/PNT DECO TXTFG TC DFAB : ENTRY/EXTERIOR SINGLE UNIT, HAMPTON CENTER ARCH,: DOOR
FABRICATION SERVICES, INC -QTY 1
Materials Price $ 1755.69
INSTALLATION DESCRIPTION
Stock or SOS : SOS Door Type : Exterior
Select Location : Front Door Select New Door : Single Pre-hung
Number of Doors to Install : 1 Side Lights or Transoms : Yes
Total Number of Side Lights and Transoms : 1 Hardwood (Mahogany or Oak) Door : No
Hidden Damage Description : None Number of additional holes bored for accessories : None
Install Specialized Mortise Hardware : No Install Storm Door : Install new storm door
Select Storm Door : Storm Door Lead Safety Practices : No
Total Linear Feet of Custom Trim to be Installed : 0 Deliver Door : Yes
Customer Understands Scope of the Project : Yes Permit Required : No
Additional Miles Traveled over 20 : 0 Bring Up To Code Description : None
Local Disposal Fee : Yes Describe Other Work Needed : build out jamb 70.00, build out ext casing 54.00
Other Work Charge : Yes Comments : No Comment
Labor Charges $ 739.0
Detail Deduction -$ 35.0
Additional Specifications:
Notation: Lowe's will not make structural modifications, paint or stain or remove/reinstall security system equipment. Customer is responsible to advise if prop-
erty is governed by Historic District Regulations.
Additional Specifications: The Environmental Protection Agency (EPA) has requested that Lowe's notify installation customers that a lead based paint hazard
may exist in dwellings built prior to 1978. See pamphlet EPA 747-K-99-001 for details.
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES [where applicable labor istaxable,checkiocal:taxresmocioos'
t' SUB-TOTA!Li $2459.6
Store 1094 Project No. 317653137 for DAVID KELLY Page 2 of 8
r
STORE COPY
'TAX $ 0.0
DELIVERY $ �0.0
ORDER TOTAL $2459.5
BALANCE DUE
Work is to commence upon reasonable availablity of Contractor which is anticipated to be '(� . [fill in date]. -
Estimated completion date is [fill in date].
NOTICE TO CUSTOMER
All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing
on this contract form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation
necessitated by defective substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to custorrn-
er.
IF THE CONTRACT TOTAL IS $1 000 00 OR LESS Customer must pay in full.
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1,000.00:
A ] Customer to Pay in Full; OR
[_] Customer to use the following payment schedule:
(1) Deposit $ _to be paid upon signing contract. Deposit should be 1/3 the total contract price; and
(2) Payment of $ to be paid anytime after this Contract is signed and before commencement of installation, I/We authorize Lowe's to do
one of the following (check appropriate box below):
[_I Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or
[_1 Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed; and
(3) Final payment of $100,00 to be paid upon completion of the installation and both parties' satisfaction.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON-
TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YO-U
HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPY
OF THIS CONTRACT AT THE TIME OF SIGNATURE.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c.142A
Store 1094 Project No. 317653137 for DAVID KELLY r. Page 3 of 8
j STORE COPY
FLOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON-
TRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET-
ARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB-
MIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L. c.142A.
By Date:
— —
L° s"s Hom, 6enters Inc
BY ) ,/ —��7` °• _ Date:
Owner C
By: _ Date:
Spouse
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION
INITIATED BY LOWE'S PURSUANT TO M.G.L. c.142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION
EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES.
WITNESS OUR HAND(S) AND SEAL(S) BELOW THIS DAY OF_",� i0 ry n I
Lowe's Home Centers, Inc.
,
By: . ;!r,'as- �� �`' - - (Seal)
Print Name;
(Seal)
Address Owner
city State/Province Zip/Postal Code Print Name
Spouse (Seal)
Print Name - -
Customer acknowledges receipt of a true copy which was completely filled in prior_to Customer's execution hereof. You the customer may caricel;this transaction -
Store 1094 Project No. 317653137 for DAVID KELLY Page 4 018 `