40 SABLE RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR, 7" edition MUNICIPALITY
USE
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revived January
One- or Two-Family Dwelling 1, 2008
This Section For Official Use Only
Building Permit Numb Date Applied::
Signature:
Building Commission er/Inspector of Buildings Date
SECTION l: SITE INFORMATION
1.1 Property Address:%,,, g
1.2 Assessors Map&Parcel Numbers
y� g
1.1 a 1s 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 11) Frontage CII
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I_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 ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Ow •rl of Record:
a6i VV0.S• 140 !i�a6kQ RA.
Name(Print) I Address for Service:
lra. Ve--'q 5-571 L
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. ❑ 1 Number of Units Other Cl Specify:
Brief Description of Proposed Work':
ba(
0 iet no`
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building $ 23 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 $ 2. Other Fees:
4. Mechanical (HVAC)
5. Mechanical (Fire
Su cession $ Total All Fees: $
Check No. Check Amount: Cash Amount:
6..Total Project Cost: $ 'Z ✓b3 ' ❑Paid in Full ❑ Outstanding Balance Due:
r,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
7 1 I$7
ROr14IA („JO.c�rl�jh License Number Expiry ion Da e
Name of CSL-Holder
�4L List CSL Type(see below)
Addre, T e Description
����� U Unrestricted(u a ily D Cu. Ft.)
�1 R Restncted 1&2 Family Dwelling
gnawrc
gig- S3z' d35X M Masonry Only
Telephone RC Residential Rooting Coverin
WS Residential Window and Stdin
SF Residential Solid Fuel Burnin�Ap2hance Installation
D Residential Demolition
5.2 Rcg�storec� Hqrym e Im rovemc Contractor(HIC)
Lowe1 kom�' _ ►Lt E 687
HIC Company Ofamel rHIC�1{egist IN�1ni&3MV �� Registration Number
((,,ll c`J7DDUf�'� 0f'77
Addr .s 10 1
611`3sf �t�` Expiration Date
Signa ure 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 AUTHORIZAT N TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L, (ly0.Ij hl VV , as Owner of the subject property hereby
authorize lr rd tL to act on my behalf, in all matters
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1> ( A 141 ON( ,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 �Ym(r<YA ��nYtl
Print Name
to 1a1 � 1'S
Signature of Owne or Authorized Agent Date
(Signed under the pains and 2cualtics of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and l I O.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 Nunmber 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"
K Ine "mmonweatin ojinassacnusetts
Department,oflndustrfal Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information �p Please Print Letibiv
Name(Business/Organization/Individual): I3OY%a1 IUMV 1
Address: I a- -roatrs a
City/State/Zip: �Wc"A l (fin oicv Phone#: q7$� 53ol-OB6A
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 1 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 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. 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
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing-repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.❑ Other
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must subrrit a new affidavit indicating such.
tContmctors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy infomation.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A�w ` merlon rnsutraCQ `,otnl my
Policy#or Self-ins.Lic.#: V t7� l��S�O ja1—[oZ Expiration Date: 10 a9 j
Job Site Address: 4o so-U'e R(1 City/State/Zip: 'Z-4 6yho fAM of 17D
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 25A of MGL c. 152 can lead to 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 statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of erjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5:Plumbing Inspector
6.Other
Contact Person: Phone#:
;L
�-\ Office of Consumer Affairs&Business Regulation
U
ME IMPROVEMENT CONTRACTOR
e pratlon CAB 88 Type
Expira 11W4W;$40 I Supplement
LOWE'S HOME8 €ffRti.#
RICHARD CHALfNP-
136 TURNPIKE R9 SFJYCE 4Q0• ��-6
SOUTH BOROUGH,rM:041M Undersecretary
c
The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR)
Consumer Affairs and Business Regulation .*VZ
Home Consumer Home Improvement Contracting
HIC Registration Complaints
Registration 148688
Registrant LOWE'S HOMES CENTERS INC
Name KEVIN BECKER Home Improvement
Address 136 TURNPIKE RD. SUITE 100 Contractor RegistrationHome Paae
City, State Zip SOUTHBOROUGH, MA 01772
Expiration Date 10/18/2015
Complaints Details
COMPLAINT NO DATE RECEIVED
2005-051-HU 09/16/2005
2009-083 03/04/2009
2012-108 08128/2012
You can also view arbitration and Guaranty Fund history,
Back To Search
Q 2012 Commonwealth of Massachusetts.
Mass.Gov@ is a registered service mark of the Commonwealth of Massachusetts.
1 Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
0,11,1111CU ) tiupV1,11,11"
License'. CS-071187
RONALD E W ACWJN
12 TUCKERS CT;3RD FL _
PEABODY MA 61960
Expiration
Commissioner 0810412015
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- IMPROVEMENT CONTRACTOR Irelore the expiration date. If t'ound return to:
e9�strotlow 13304 Type: - Office ul'Cansurnur Afrnirs and Business Regulation
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CERTIFICATE OF LIABILITY INSURANCE
-tWBFFRTIFICA7E IS ISSUED AS A DATE lMM/OD/YYYYI
CERTIFICATE DOES MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO LDE THIS THIS CERTIFICATE NOT AFFIRMATIVELY FOR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,REP OF INSURANCE DOES NOT CONSTITUTE A CON7RACTEEMJFFN THE ISSUING INBURER(3),AUTHORIZED
REPRESENTATIVE UCER AND CERTI FIC LDER.
IMPORTANT:If the eertlOCate holder Is an ADDI NO
he terms and conditions O NAL INSURED,the pollcy(les)must be endorsed, if sUBROCAnON IS WANED
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h entlorealime qg�es may.egyjre and endorsement. A statement o0 this cOrtlOcate does c.Ito
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PRODUCER
CONTACT
WO()DINC P 1 INS AGCY IN NAME:
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HAWSE THE INSURANCENCEAFFORDED BY THE PCLICIE'S DESCRIBED HEREIN 199UaIECT TO ALL THE TERMS,EXCLUSIOHSANDCONOHIONSOFSUCHPOLICIEB. LIMITSSHONMMAY
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GENERAL LIABILITY —.--.- _._. LIMAS
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REMISES(Ee..corm...)
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CERT)FICATE HOLDER
LOWS$COMPANIES INC CANCELLATION `--
IS INSUR
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
A)V(_fE BRPORE THEEXPIRATION DATE THEREOP,NOTICE INILL I —
FO BOX 1 I I IN ACCORDANCE'WITH THE POLICY FIR _ DELI
NORTH VIL IZED REPRESENTATIVE
I.ICES&JKU,NC T(i55e AUTHOR ----
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Inc. DNLVAn2 CONFERS I NO REOHTS UPONrTHE CERTIFICpTE�ON
40 Main St. HOLDER,THIS CERTIFlCATE DOER NOT AMEND,EXTEND OR
P.O. BOx 353 /�'� ALTER TWE COVERAGE AFpORDED BY THE POLICIES BELOW.
Peabody, NA 01960 INSURERB AFFORDING COVERAGE
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12 Tuckers Ct. CCRNERCE INSURANCE cOMPANIY 347S4
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THE POLICIES OF INSUR4NCEOR LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY PERTAIN.THE I TERM$1 OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 9E ISSUED OR
MAY PERTAIN,THE INSURANL`E AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.w
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005 Ford FS50 Super Cab IFDAX57YISESS445 200S CARMATE TRAILER SAK816D45L0104538
000 CARMATE TRAILER 5A3C6105%L0004012 2002 DODGE DURANGO 184H578X62F118138
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--
TION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED OEFORE THE
EXPIRAMM DATE TNIREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
LOWI 'S COMPANIES, INC. 10 DAYS WRITTEN NOTICE TO THE CEtTIPM.ATE HOLDER NAMED TO THE LEFT,
IS INSURANCE BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIAMUTY
P 0 BOX III OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.WILKEBORO , NC 2afiS6 A TH REPHRSE1TATNE
ACORD 25(209il08) FAX: 336.658.2308
CACORD CORPORATION i988
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INSTALLATION STREEr ADDRESS CrY STATE ZIP
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OnP P iur (Jng P!
-
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Contract Total if - 60
Are permits required for this installation?:4 Yes [ ]No applicable tax included
NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right.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 chwIling unit.
PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees the right to lake photographs of all work performed at the Premises related to this
Contract,and irrevocably grants to Lowe's all right,title and 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 Lowes may use such
photographs for any lawful purpose, including,but not limited to,marketing, advertising, publicity, illustration, training and Web Content. By initialing
here,Customer agrees to the foregoing. (Customer to initial to the Ieftl.
Work to to Comm//rice yyPpoon reasonable availability of Contractor antllor any special order or c stom matle Goods)which is anticipated to be
// /97//3 [filla In date].Estimated completion date is /1 r27 /i _[fill in date).
Said estimated substantial Completion date is not of Me essence. A statement of any Contingencies that would materially change said estimated substantial
Completion date is as follows:
(d applicable,inserts statment of such Contingencies).
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full.
CQMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00:
( Customer to Pay in Full; OR [ ]Customer to use Me following payment schedule:
(1 Deposit$ to be paid upon siging 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 me following(check appropriate box below):
( I Charge my/our Credit cam for the amount of the payment indicated above anytime after the date this Contract is signed;
or
[ ]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.
NOTICE REGARDING ARBITReUON AGREEMENT FOR GLeIMS GOVEREDBYMGL'. 1y, 42? '
LOWE'S AND OWNER HEREBY MUTUALLYAGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT
LOWE'S MAY SUBMIT SUCH 0 SP TE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN PPROVED BY THE SECRETARY OF THE EXECUT-
IVE OFFICE OF CONSUM RAFF R AND BUISNESS REGULATIONS AND THE OWNERS LL E REQUIRED TO SUBMIT TO SUCH ARBITRATION
AS PR DIN .14
By: Date: /O Z7
Lowe's Home C Inc nlers, .
By: r Date: /Dh3/ ,
Owner SigItem
`
THE SIGNATURES OF THE PARTIESA OVE 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.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND
CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.
BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE
TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS
CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE.
WITNESS OUR HAND(S)AN L(S)BELOW THIS DAY OF !NT/C'.FO P/— ,42a3
ome e
c tan
Specialist or Above Owner Co-owner or Witness
Customer acknowledges receipt cif a We copy of this Contract which was completely filled in later to Customer's execution hereof.You,the buyer,may
cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the attached notice of cancellation
form for an explanation of this right
#90981(Rev.12/70) FILE COPYre°yg'�e�e`twierelo N LFecebWnzo .