2 SPRUANCE WAY - BUILDING INSPECTION bly
-'. - The Commonwealth of Massachusetts
�A
/ Department of Public Safety
,X_.�1. ::\iassachusots Stale Building Cute(780 CMR)
`"-"•' Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number _ _ Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block 0 and Lot p for locations for which a street address is not available)
�� - of 9 ao -
No.all Street dy/Town Zip Code N,mte of Building(if applicable)
SECI'lON 2:PROPOSED WORK
Edition of MA Stale Axle used - If New Construction check here❑or check all that apply in the two rows below
Esistiny, ISuilting❑ Repair Afteratiou ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction drxumetts being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:__
IV
B c!i W!n ufS
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s): _
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq, ft)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-.i ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
I? Facto F-1 ❑ F2❑ H: High Flazard H-1 ❑ H-2❑ 14-3 ❑ FI-4❑ 1-1-5❑
1: Institutional I-1 ❑ ,1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage 5-1 ❑ S-2❑ U., Utility❑ F Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ HA ❑ 118 ❑ IIIA ❑ - 111813 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permib. Debris Removal:
Public❑ Check if outside Flood Zane❑ lodlC.ne municipal❑
Atrench will not be I"iarnsrd Uispusal Site❑
squired ❑or trench or specify:_____."_.__
Private❑ or mdenlify Z-Onc: or ou site system ❑ permit is onCloscd ❑ _____ _ _
Railroad right-of-way: Ilizards to Air Navigation:
Not :\pphcablc❑ Is Structure rr ithm airport approach area? Is(heir«:viers nnnj+lclrt'
Or Consent to Built enclosed ❑ 1 1 es❑ or:No❑ ),.S❑ No ❑
SECTION B:CO NTEN"r OF CE RT119CA'LE•OF OCCUPANCY
Wilma of Code: L'se Gnnip(s): 1%pe of Coosiructiou: _ Occupant I ood per 1:1nor:
DUl'] Iltr building,contain an Sprinkler Sysh•m?:_.__ _ ___SpeCial Stipulations: ____
SECTION 9: PROPIlt I'Y OWNER AUTHORIZATION
IN t ,uul Address of l'ropt-rtN'C)taner
pru elf?c( i Ieln [�
Nanpc(Print) No. oilStreet City/Town Lip
Prey. rK:, 't Information: -
77? 003
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, to property owner hereby authorizes
/nr�d J00 e2d ,JV1kt /tea n^¢�/7a1
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to%cork authorized by this building ennit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildin•is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and skip Section Ill.l
10.1 Registered Professional Responsible for Construction Control
&& sq- 611 1 t-OW-77
oName(Regis t utt Telephone N c-mail address Registration Numbers 16 / 7
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Ae
Company Name 01
/'�?c/�46/ f. � /57,408 114'6-
Name of Person Responsible fo Construction License No. and Type if Applicable
Street Address City/Town State Zip
Tole phone No. business Telephone No. cell e-nail address
SECTION 11:w(?r.1.hrS;'( 0n1I1I,_V,n_I'LN l�V-:1JI:AN(F AI 11-11"•VI I M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be annpleted and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 11 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item b)_$
I. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor) _$
t. Plumbing $
1. \lechanical (HV.AC) $ Note: Minimum fee=$ (col N act mull alily)
5. cchni acel (Other) S\I —
F.nclose check payable to
6.Total Cost $ (contact municipalihv)and larite chec number here _
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Be entering nn' name below, I hereby attest under the pains end pcnahics of perjury limp all of the inhm a m cootdincJ in this
application is true and accurate to the best of nay know ledgen]understandiog.
12ud1_C r�Lf� Pi - 09110—
I'Irasc pnn m 1 ign t •am Tillc 1'rl•phon 1 p. U,uc
tilreet Address City/rocvn State Zi
Municipal Inspector to fill out this section upon application approval: _ _ I�� I�J
Name Date T
x�.
The Commonwealth of Hassachusettc Print Form
Department of Industrial Accidents
Y] i= ('4
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 Pease Print Legibly
Name (Business/Organisation/Individual): UA-'+eJ fferkL G�`Y`�tf Urt, ret! P0'A1k2
1 pnn
Address: 0)_00 . pklfltler7lpIot by S✓;}LTj r
City/State/Zip: Ia'k1l /1V1 - 01 '7st-1 Phone 4:
Are you an employer?Check the appropriate box: Type of project(required):
1.Q I am a employer with 'F__ 4. ❑ I am a general contractor and]
6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. ' 7. R Remodeling�jeq/ace
ship and have no employees These sub-contractors have g. ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P tY 9. ❑ Building addition
[No workers' comp. insurance comp.insurance?
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] + c. 152, §1(4),and we have no
employees.(No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box kl 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 submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance jar my employees. Below is the policy and job site
information. t-
Insurance Company Name:—
Policy 4 or Self ins.Liic.9:[_� _\-fit Q e� (9 �' 13-5 V Expiration Date:
�
Job Site Address: + aVrULt0Ce- w V City/State/Zip: �Zl�l°il ►1 jm.4 , 019?o
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 a 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.
e—
I do hereby certi y under the aims and en ies aftierjury that the information provided above is true and correct
Signature C /2�.C�i�-Gr/ /,L�_ — Date d t'1
rr
Phone#: 5-06 TV ylr(f r
Official use only. Do not write in this area,to be completed by city or row"official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. CigTFown Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF S.U-&NI, NWs,kcfjL:SETTS
8LILDLNG OEP.1ATlE\T
120 W.l3NLVGTON SMWT. 1'O Rccit
169L (978) 745-959S
KIAMEA1 SY DR)SCOLL FAX(978) 740.984d
MAYOR T{oua Sr.pmlus
DIRECTOR OPPlBLICPROPff1 Y/9t:MD YGCOSp1ISSIONER
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 1
Debris, and the provisions of MOL a 40. S 54;
Building Permit 10 is issued with the condition that the debris resulting from
this work shall be disposed of in a p
11 I, S I SOA. roperly licensed waste disposoi facility as defined by NIGL c
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
r
(iddrela or rj.d,jy)
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National Fenestration
Rating Caporal®
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ENERGY PERFORMANCE RATINGS
EVALUACION DE RENDINNEWPO ENERGIEFIC0
J-Factor Solar Heat Gain Coefficient
Factor-U Coeficienno.Gananda de Energia Solar
-2
ADDITIONAL PERFORMANCE RATINGS
EVALLIAC40N SUPLEMENTARIA DE RENDINVENTO
Visible Transmittance
Transinnision de UaVisible
Mmd&'turff Stipulates W thm orange Womn to aPPUCathe NFIC procedures for determining whole MW perforarence.NFRC
ratings are detennnea for a fireed set of errvinarmanded oandandam and a specific Wool size.NFRC dm not readerappord any Product
and does nut Warrant the witability of any POW for my spedfic use.Cahoot haroutamees anarame forage product parlmmance
lardonnnation.wwwriftc.ori
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Este falurnomaD entioula quo esM valores mmom can las proce(firreellm aplicables de NFRC ima"new 01 rerinfirriento 1*1 del
Waco.Los valares;mdm M NFRC son derthentinadas par un=junto fjo do condicioneor;arnblentain y m tannerepi de prodol
especifica.NFRC no reconnienda nloWn MM)Lb Y M Waftfim que el producto seat ademedo pare on=eWedfi,,Ornsulte,am at
fl(181 fabill age el USO ophipiado de este produclo.wwwnft.org
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Keep this label for possible ENERGY 5TARO rebates,is learn more visit wwwanerlillstaLgov
Guorde asto efiqueta pule posibles feembolsars ENERGY STAR?Palo(mocei lads aceno do esto,Vispe WWWapalgyShULg0V.
,ACORQ CERTIFICATE OF LIABILITY INSURANCE OP ID DD. DATE(MIN OD YYYY)
UNITE51 08 1S` 11
PRODUCER_. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
East Douglas Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
PO Box 1370 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOWI
Douglas MA 01516
Phone: 508-476-2101 Fax:508-476-1296 INSURERS AFFORDING COVERAGE NAIC i
INSURED INSURER A fl .tern Rlorld Io�IrNuwe Co. I
INSURER B. COmOVerce Insurance Company 34754 _
United Painting Company Inc pNSImERO SeottAdale iRAlranee CoapaEW
200 Butterfield Drive, �vite I NSURER o: AAsxlAtea �loyacA Ioso>:A�o
Ashland MA 01721 j
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT.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 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. .
LTR NSRE TYPE OF INSURANCE POLICY NUMBER DATEY(MMfDDFM DATE(MVJDDfM LIMITS _
GENERAL LIABILITY EACH OOCAIRRENCE L 1,000,DOD _
A X COMMERCIALGENERALU-BILITY NPP0023401 04/15/11 04/15/12 PREMISES emeenee $ 200,000 _
CLAIMS MADE X❑OCCUR MED EXP(Any one pawn) 25,000
PERSONAL M ADV INJURY $ 1,000,000
GENERAL AGGREGATE $2,000,000
GENL AGGREGATE LIMIT APPLES PER: PRooUars-COAPIOP AGO $2,000 000
POLICY � LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIAIT
B ANY BDGTQN 04/15/11 04/15/12 (E. .d ,Q s 1,000,000
ALL OWNED AUTOS
BODILY INJURY S
X SCHEDULED AUTOS (P�paSO^)
X HIRED AUTOS GODLY MARRY I i
P X NONOWNED AUTOS Pin e d..O
I PROPERTY DAMAGE
? IPa+..daN
I i GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANYAUTO OTHER AN
EAACC I
AUTO CNLY: AGO I
otCCSsRnRBREUA LLABIIm EACH OCCURRENCE s4,000,000 _
C X7 OCCUR F-�CLARAs MADE XLS0073744 04/15/11 04/15/12 AGGREGATE s4,000,000 _
s
DEDUCIBLE $
RETEN110l1 5. s .
WORKERS COMPENSIITIDH TWO
D EYPI5LN&1IY
, >PROR . QQ12669-13568 08/15/11 09/15/12 E.LTEOtCRYH LAMCCIOTSD ENTX ER $500,000� XRLBFQIRDCr —
_
E.L.DISEASE-EA f5001000 - _
5 -C!ALPRoeew., eL_DIseASE-PoucY LMMIT s500 000
m ER
DESGNo'•ITON OF OPERAl10N5I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
RSu�plelaeatal Name•
Vniteti Painting Company, Inc DBA United Home Experts t United Painting
Company.; LLC ..
CERTIFICATE HOLDER CANCELLATION
UNITP02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
United Painting Conpany, Inc. IMPOSE NO OBLIGATION OR UABIL MY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
200 Butterfield Drive, Unit I REPRESENTATIVES. It 54
Ashland MA 01721 AUTHORIZEDREPRESENTATIVE.
Marc Laro e
ACORD 25(2001108) ` ®'ACORD CORPORATION 1
��Ottice of onsumer Af air -andWBua esssegul�n
i
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 157108
Type: Supplement Card
UNITED HOME EXPERTS Expiration: 9/5/2013
MICHAEL DUDLEY
200 BUTTERFIELD DR STE I
ASHLAND, MA 01721
Update Address and return card. Mark reason for change.
)PS-CAI Co 50M- Address .Renewal Employment Lost Card
OC/046/1�012160
L/dliNnlY�1u/eatf/L 6�✓G�dOpC/[Ud8�4
Office of Consumer Affairs& Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration: Type: 10 Park Plaza-Suite 5170
Expiration,.;;g/5/2013 Supplement Card Boston,MA 02116
UNITED HOME EXPERTS
MICHAEL DUDLEY i?
200 BUTTERFIELD DR,STE I
ASHLAND,MA 01721
Undersecretary Not valid without signature
y
i
�: \lax.actin>cn. - I>i•p;tn mr,n �. Tuhlie jali•tx
Bwitd oil 9tiildit,-, Rc,Ulatimis and Slarid.irds
JJ Construction Superv,so, L!cer,se
License: CS 100077
Restricted to: 00
MICHAEL DUDLEY
137 CENTRAL ST UNIT 3 -
ASHLAND, MA 01721
"L Expiration: 5/6/2012
1
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