35 RAYMOND RD - BUILDING INSPECTION (2) A
The Commonwealth of Massachusetts
r °A Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Proper5 Addres • 1.2 Assessors Map& Parcel Numbers
3 � �avmon
I.I a 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(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?
Check if yes❑ Municipal ❑ On site disposal system ❑
2.1 wner' SECTION2: PROPERTY OWNERSHIP'
of ec or
Ie 5�(efn t m 01970
Name(Print) City,State,ZIP
3S Rumona ?A.
No. and Street I Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
Kolnalkt( fae4 Q�, 5 1
D �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ Other Fees: $
L
4. Mechanical (HVAC) $ � List:
5. Mechanical (Fire
Suppression) $ Total All Fees: $
6. Total Project Cost: $ %
Check No. Check Amount: Cash Amount:
6►IpJ-'
• ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) '] It $1 a
Kan 11AA License Number Expirati n Date
Name of CSL Holder
o, List CSL Type(see below)
No.and (reel Type Description
f I t r A o( q f Z) U Unrestricted(Buildings u to 35.000 cu. ft.)
t R Restricted 1&2 Family Dwelling
City/Town. State.ZIP M Masonry
RC Covering
Window
WS Window andndSidin
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Im.,prro-veemeJgtnCo-nitrac�tjor(HIC) � 416SE t,,��,�y
La"** 146m e.. Unk^ / R(Cj'I ra c ►aiw HIC Registration Number Expiration Date
HIC Company Name rrr�HI� e istran Name
'IUfIlO1fK f. g
fic)7cird.C{iy�cnC l_S16/Q.(o e3 Ga
4�Stre�Lt p �[
SJOVA'6rutA6 , Inn, o('7-72. 417-259--7'I'o Email address
-City/Town,State,AP 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 AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Las Owner of the subject property,hereby authorize_ -i;4} &riA C-�)ca.ltn q
to act on my behalf, in all matters relative to work authorized by this building permit application.
n-ly � N&k*) 6.;�7 ,�f
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER( OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this ap 5 2y
plicationrue and accurate to the best of my knowledge and understanding.
i0 ' ''7
I rent wner'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.sov/oca Information on the Construction Supervisor License can be found at www.ntass.vovldps
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"
/{G 'LV//L//{V/LYYG4L{/{ Vf Ill WJJLLL/LLLJ llJ ..a�,nm.ea.+'sv>ea-uti
eat Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
IV
Workers' Compensation Insurance Affidavit: Builders/Con ractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: I AT G*
City/State/Zip: TM6CJ !n DI 96 D Phone #: f7f "53,1-035,L
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with_i 4. ❑ I am a general contractor and I
employees (full and/or part-time).
e have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
.workers No myself. ' com right of exemption per MGL
y [ P 12.❑ Roof repairs
insurance required.] f c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensE tion policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contract rs and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my emp Foyees. Below is the policy and job site
information.
Insurance Company Name: y PKAA tlCAA
Policy# or Self-ins. Lic. #: V B^4$oS { of f� Expiration Date::
Job Site Address: 55 RAYmenG IVA Cit /State/Zin: $p14l'M!t Mij- 01970
Attach a copy of the workers' compensation policy declaration page(showing he policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead i o the imposition of criminal penalties of a
fine 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 statemer t may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby eerti r the gains and genalties o e 'u that the information Provided above is true and correct.
Si nature: DE to
Phone#: -7 " 3
Official use only. Do not write in this area, to be completed by city or town of Mal
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electri al Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
,q ��C-(PIP/LP/t UKY/l[/1 P`Ci��USiUC�WC(t'.
f<ce of Consumer Affairs&Business Regulation
d k,: g License or registration valid for individul use only
.1 tZ ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Cdnsumer Affairs and Business Regulation
,'Registration.-148688 Type- 10 ,
- .5 Supplement Ward Park Plaza-Suite 5170-
Expiration: 10/18/201 Su pp Boston,MA 02116
LOWE'S HOMES CENTERS INC
RICHARD CHALONE
136 TURNPIKE RD.SUITE 100
SOUTHBOROUGH,MA 01772 Undersecretar
y Not valid without signature
`OLI ._ .
1�( Massachusetts - Department of Public Safety
Board of Building Regulations and Sta dards
( umtntainn Supcni. r
License: CS-071187
RONALD E W ACOLIN
12 TUCI ERS CT;3RD FL
@EABODy MA 4%960
xpiration
f /04/2015
Commissioner
b
( ...
,nY Ottiar of Cansumer Affaira&naridesx Hepulatioe License or regi trntion valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiation data. If.found return to:
`• agtstrIMPR 1MENT Type: office urcmtsl lnor Afroirs and Business Regulation
piratiom. 6/27/2015. DBA 10 Pork Plaza Suite 5170
floston,MA 02116
.e
RONCO CONSTRUG11OW
RONALD WACHLIN " / /
12 TUCKERS CT. ,.z�.s.F.,�_Er•b / . ;�,
PEABODY,MA Q1950 Unders¢crelory Nut alid Witham signature
STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK- INT/EXT/PATIO DOOR
LOWE'S OF DANVERS, MA., STORE# 1094 STORE PHONE: (978)646-9099
-�— - _r- - - - 1.53-ANDOVER-STREET ------ -SALES PERSON:-BERNARD-S-T-UBBS -
DANVERS, MA 01923 SALESPERSON ID: 1503347
Document Print Date :05/26/2014
This is only a Quote for the merchandise and services printed below.This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree-
ment, including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, 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, LLC's MA HIC NO.: 148688 Lowe's Home Centers, LLC's FEIN: 56-0748358
Customer Name Home Phone
S MICHELLE NEWTON 617-435-0775
O Customer Address Other Phone
35 RAYMOND RD
L City State/Province Zip/Postal Code
D SALEM MA 01970
Installation Address
T 35 RAYMOND RD
O Installation City Installation State/Province Installation Zip/Postal Code
SALEM MA 01970
M R -HANDI4 AND INSTA ATI�N S 6�R�ARY
MERCHANDISE SUMMARY
1046 : 87544 : STK : 3/4-IN X 3-1/2-IN X 4-FT RD OK BID : 3/4-IN X 3-1/2-IN X 4-FT RD OK BID : BABCOCK LUMBER -QTY 1
7056 : 94710PINE : STK : PNE STOP 947 3/8"X1-1/4"X10' : PNE STOP 947 3/8"X1-1/4"X10' : EMPIRE COMPANY, INC. (THE) - QTY 6
47970 : LW5000 : STK : CLEAR W&D SILICONE II 9.8 OZ : 9.8-OZ CLEAR SILICONE WINDOW AND DOOR CAULK : MOMENTIVE PERFORMANCE MA-
TERIAL-CITY 1
131207 : 131207 : STK : 1X8X16 PRIMED FNGR JNT(+333358) : 1X8X16 PRIMED FNGR JNT (+333358) : IRVING FOREST PRODUCTS (MAINE)- QTY 4
48552 : PEMSINGLEDR : SOS : SOS PELLA ENTRY 650 SERIES TC : PELLA (R) BRAND ENTRY DOORS SINGLE DOOR ***THIS PRICE REFLECTS A
15%OFF PROMOTION ON SOS PELLA (R) ENTRY DOORS - 5/14/14 TO 5/27/14*** : PELLA - ENTRY DOORS - QTY 1
89061 : SIGNATURE CLEAR BRAS : SOS : SOS COMFORTBILT STORM/SCRN DOORS : LARSON, SIGNATURE CLEAR BRASS BLACK 30 79 ****15%
Store 1094 Project No. 409312251 for MICHELLE NEWTON Page 1 of 8
STORE COPY
OFF PURCHASE OF SPECIAL ORDER OF LARSON DOORS. OFFER VALID 05/14/2014 THROUGH 05/27/2014.**** : COMFORT-BILT WINDOWS AND
DOORS - QTY 1
- --8906-1-SIGNATURE CL-EAR-BRAS-SOS-SOS-COMFOR-T-BILT--STORM/SCRN-DOORS-LARSON, SIGNATURE-CLEAR-BRASS-BLACK-34-82--*-*45%-- -
OFF PURCHASE OF SPECIAL ORDER OF LARSON DOORS. OFFER VALID 05/14/2014 THROUGH 05/27/2014.**** : COMFORT-BILT WINDOWS AND
DOORS - QTY 1
326796 : PRODUCTCODE : SOS : SOS RB PNT/PNT COMM SM FG TC DFAB : ENTRY/EXTERIOR SINGLE UNIT, FLUSH ***15%OFF RETAIL ON ALL
SPECIAL ORDER ENTRY DOORS FROM 05/14/14 THROUGH 05/27/14*** : DOOR FABRICATION SERVICES INC - QTY 1
377527 : 90846 : SOS : OLYMPIA 30" WHITE : SINGLE STORM DOOR HIGHVIEW STORM ****15% OFF PURCHASE OF SPECIAL ORDER OF PELLA
STORM DOORS. OFFER VALID 05/14/2014 THROUGH 05/27/2014.**** : CLO LARSON MANUFACTURING COMPA -QTY 1
Materials Price $ 2376.02
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 : No
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 : Replace existing storm door Lead Safe Practices : No
Stock or SOS : SOS Door Type : Exterior
Select Location : cellar Select New Door: Single Pre-hung
Number of Doors to Install : 1 Side Lights or Transoms : No
Hardwood (Mahogany or Oak) Door : No Hidden Damage Description : None
Number of additional holes bored for accessories : None Install Specialized Mortise Hardware : No
Instaii Storm Door : No Lead Safe Practices . No
Stock or SOS : SOS Door Type : Exterior
Select Location : Back Door Select New Door : Single Pre-hung
Number of Doors to Install : 0 Side Lights or Transoms : No
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 Safe 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 of jambs, cover doors with aluminum Other Work Charge : Yes
Store 1094 Project No. 409312251 for MICHELLE NEWTON Page 2 of 8
STORE COPY
trim , build out for storm doorsfix sils and add oak
Comments : 2 doors front and side
Labor Charges $ 2270.00
Detail Deduction $ 35.00
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:Federal law requires Lowe's to provide you with the pamphlet Renovate Right: Important Lead Hazard Information for Families,
Child Care Providers and Schools. By signing this Contract, Customer acknowledges having received a copy of this pamphlet before work began informing
Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit.
PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photograghs of the Premises where In-
stallation Services will be performed and all work performed at the Premises related to this Contract, and irrevocably grants to Lowe's all right, title, interest in
and to the photographs for use in all markets and media, worldwide, in perpetuity. Customer authorizes Lowe's to copyright, use and publish the photographs in
print and/or electronically, and agrees that Lowe's may use such photographs for any lawful puAoTa!
ding, but not limited to, marketing, advertising, publi-
city, illustration, training and Web content. By initialing here, Customer agrees to the foregoing. _[Customer to initial to the left].
NOTICE TO CUSTOMER-PRICE CALCULATIONS: In order to properly perform the installatio Goods, the Contract Price may include more Goods
than actually will be installed based on the measured square footage of the Project Area. As a result, the parties agree that the lump-sum Price stated in this
Contract is calculated upon both the value of the estimated Goods required to fulfill the Contract(including waste), which may exceed the actual square footage
of the Project Area, and the labor which may be estimated based on the amount of Goods required to fulfill the contract (including waste). By signing this Con-
tract below, Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the
Installat an Services arePerffirmerl
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES 'where applicable
SUB-TOTAL $ 4611.0
'TAX $ 0.0
DELIVERY $ 0.0
ORDER TOTAL $4611.0
BALANCE DUE
Store 10.94 Project No. 409312251 for MICHELLE NEWTON Page 3 of 8
STORE COPY
Work is to commence upon reasop4bliavail ity 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 custom-
er.
IF THE CO TRA T TOTAL IS$1,000.00 OR LESS, Customer must pay in full.
COMPCETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS 1 000.00:
Customer to Pay in Full; OR
(_] Customer to use the following payment schedule:
(1) Deposit of$ to be paid upon signing contract. Any deposit collected at the time this Contract is signed will not exceed one-third (1/3)
of the contract price; and
(2) Payment of $ to be collected upon or after the commencement of work. I/We authorize Lowe's to do one of the following (check ap-
propriate box below):
[_] Charge my/our credit card for the amount of the payment indicated above upon or after the commencement of work; or
Deposit rny�our check for thp amo,int of!he payment inrl rntpri ghmip Anytime upon or after the CnmmAnr.PmPnt of wnrk' And
(3) Final payment of $100.00, to be paid upon completion of the installation to 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 YOU
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
LOWE'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-
Store 1094 Project No. 409312251 for MICHELLE NEWTON Page 4 of 8
17 STORE COPY
MIT TO S H ITRA PROVIDED IN M.G.L. c.142A.
By: Date:
Lo - �C — ,/ -- -- - - -- -
By: Date(l
Owner
By: Date:
Co-owner or Witness
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 S AL(S) BELOW THIS DAY OF 1 .
Lowe's Home Centers, LLC
By' (Seal)
Print Name:
Address (Seal)
Ow er
�2 J�f SH 4"N f�(F cd JJ
Co-Owner or Witness (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 cancel this transaction
at any time prior to midnight on the third business day after the date of this transaction. See the attached Notice of Right to Cancel for an explanation of
this right.
Store 1094 Project No. 409312251 for MICHELLE NEWTON Page 5 of 8