47 SUMMIT AVE - BUILDING INSPECTION (3) 66-
CA— 9 -7
RECEIVED
IN
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards �j�
1 / Massachusetts State Building Code, Igo CMR1015 APR -9 e4aer7, ar1201!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
( =Buildin
This Section For Offici Use Only
,
V l . Date ppliedS
ame). Signature- Date
SECTION 1:SITE INFORiv1AT10N
1.1 Property Address: A✓ Eftoperty
Ninp Rt Parcel Numbers
�Id `7 S u rt �vr
I.1 a Is this an accepted street?yes no Parcel Number
1.3 "Zoning Information: Dimensions:
Zoning District Proposed Use Frontage(Il)
1.5 Building Setbacks(R)
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 es❑
SECTION2: PROPERTY OWNERSHIP!
2.1 Ownert of Record:
_S AI Pam+ (Y1
N7 me(Print) City,State,ZIP
1A'--) 5 (g1 7�qRS 3126
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Buildi Owner-OccupiedcP Repairs(s Altemtion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': f p v Pof� a O ! R a lGre AMA
� x . StNiet2onF SArnr+ 4'1 ;9-o -- k' Ranr- Ceie,Vg
v S iTa Ca t.q'Tr 02 on Ft.✓�
SECTION a:ESTIMATED CONSTRUCTION COSTS
Itctn Estimated Costs: Official Use Only
Labor and Materials)
I. Building S co I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cose(Item 6)x multiplier x
3. Plumbing $ !�,(gtherFees: S
d. Mechanical (HVAC) S List:
5. Mechanical (Fire $ Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:
6.Total Project Cost: .S (..I; r 5'7-5 o ❑Paid in Full ❑Outstanding Balance Due:
"N COP.)T
Mri,v>✓>go
SECTION 5: CONSTRUCTION SERVICES t
5.1 Construction Supervisor License(CSL) Cl 4-1 6:3.
' License Number Expiration Date
Name of CSL[folder List CSL,rype(see below)
,-3 t- C4J s', PP,A Type Description
No. and Street s
M U UnrcstricteJ(Buildings u to 35,000 cu. tl.)
�,O,A b 120K 1 1 A ® 1 Ck 4-b R Restricted 1&2 Family Dwelling
6tyfruwn,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
q "1,g fj"'1�1 `��_�� I Insulation
Telephone Email address D Demolition
5.2 Registered home Improvement Contractor(HIC) 1 0 O 8 1 ) 6`23`11
L—o,✓ G, 6 a-,-L-Y CoAl-r— HIC Registration Number Expiration Date
Ifl Z�Sve 6t 7 LHCRTgo ,nt NSeT
yYee)PYMAQ% `t60
97R5 318>iM Email address
City/Town, State ZIP 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...........O
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED W H ENl -
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Na ne(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's Authorized Agin Namc(Electronic Signature) Dane
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 NI.G.L.c. 1 d2A. Other important information on the HIC Program can be found at
www mass"ov:'oca Information on the Construction Supervisor License can be found at www.nlij . ov:'Jus _
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. 11.) 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. "foul Project Square Footage"may be substituted fix"rot l Project Cost"
l
--
*r' The Commot(weaith of Mgsspchusetts
Department ojlnduslrial Accidents
' Orice oflnvestlgations
1 CongreA Street Suite100
Boston,MA 02114-2017
wwwneassgoy/dirt
Workers',Compensation Insut'ance.Affidavit: Builders/Contractors/Electric
Applicant Information
Please Print Leelbly
Name (Business/Organization/Individual): L 4. b P IL V u ..'i!2
acrl cn
Address: a:3 t2 i-t..J ,+'T' e z 5�
Ci /State/Zi : t a•
o ;. Phone#: �(�1 $
Are you an employer?.Check the'appropriate box.
1.® I am a employer with o1.' 4. Ell am a Type ofproiect{required):
general contractor and I
employees(full and/or part-time).* 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-contractorwhave
working for me in any capacity. employees and have workers' S' ❑Demolition
[No workers' comp, insurance comp.insurance.: 9. ❑Building addition
required.] S. ❑ We are a corporation andats_ 10:❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers lave exercised their 11. Plumb'
ng myself. [No workers' comp. right of e$emption per MGL '�airs°r additions
insurahce'requirrA]t.- _ c. 152,§1(q),and we have no 12.❑Roof repairs
`employees:"[Noworkers' 13.[]Other
ld
P.
urance
'Any applicant that checks box#1 most also fill oat the section beloww shoes wbdter�rs ] sation h
t Homeowayrs who submit this affidavit indicating they are doing all wo a�nd.thin hive outside coafiactois must submit s new affidavit indicating such.
tCoatntctors that check this box must attached an additio�l sheet showing the naive of the subcoogactots'em nd state whether n w not those endues have:h
employees. If the sub-contractors have employees,they must provide their workers comp..Poficy number.
am an employer that 1sprovW1ngwqrkqrs1 compensation Insurance or my em
information. f ployees. Below is tke polJcy and Job site
Insurance Company Name:_ = M r "1 v'T"V A Cr
nvcr� t? At, c �o
Policy#'or Self ins. tic #: Z WC i 0 d b 6 I t7 `f'Y4f 1(yt4riExpira
_on bite:
Job Site Address: (- '1 SU c+► tT �gr a City/5tate/Zap:
Attach a copy of the Lo
workers' compensation policy declaration page(showin the policy, ff t
Failure to secure coverage as g.. . P y cumber and expiration date).
S required uuder,Section 25A of MGI c. 152 can lead to.the imposition of criminal penalties ofa
fine up t$ 50. 00 d 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 ofthe.,AlA.for insurance,coverage.:verificarion.,;. . :• : :
I do hereby certify under the�ondP fP l+nr! that the Information provided above.ls true and correct
englties_o er'
Do
14
Phone
OJrcial use only. Do not%v?*e in this area,td beronnpleted by city or town oJJrcial.
City or Town:
Permit/Liceuse#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.CltyiTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person•
Phone#:
LENGIBELYCONTRA Streetage No.�of Pages
CO.,O., INC. 26500 PROPOSAL
` 23R Winter Street
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
4 (978)631-8234 Fax(978)531-9304 engaged In home Improvement contracting, unless
www.lengibelycontracting.com specifically exempt from registration by Provisions of
Chapter 142A of the general laws,must be registered
Submitted /� A� with the Commonwealth of Massachusetts.Inquiries
bet—•J To:_. t7;1I _�j� —_— about registration and status should be made to the
Director, Home Improvement Con301, B ct' n, MA
iN' Uf1M r One Ashburton Place,Room 1301, Boston, MA 02108
2 (617) 727.8598. Owners who secure their own
construction related permits or deal with unregistered
h---- --—.D-------- contractors will be excluded from the Guaranty Fund
Provision of MGL C.142A.
PHONJ�' r7 nn � PATE.,7`'J REGIBTKATIONNO.
736 r�p �� MA.REG. 1008114
dO�PM/No toe LOCATION S�h� ILLr� /V-�Ovp
We hereby submit specifications and estimates for work to be performed and materials b be used: PO
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WORK SCIL-
ContraE
cto ig6 work�r�r�9r/Lg¢ey(�r�lels before the third day following the signing of this Agreement,unless s ecifted herein writin Cd bB in No work on or
about (det9(.IIer nd g tlb16y caused by circumstances beyond Contractor's control,lfle work will be completer te).The Owner hereby
ecknowletlg and agrees Nat to scheduling dates are approximate and Nat such delays that are not avadable by the Contractor shall erect as o a one of this A reement.
Hoden not orwMiLom not seen at lime of estlmats Met are required to be repelmd In oNer to Complete the wntoxi we be mmpated in$ A permenhour(lMN HO R).
WARRANTY
The Contractor warrants that Me work furnished hereunder shall be lme from defects in material and workmanship for a period of having completion and shall comply with
me requirements of Nis Agreement.In the event any defect In workmanship or materials,or damage Caused by to Contactor,his subcon c he employees or agents.Is discovered within
one year after completion of any lob,labia ing Clean up,the Contractor shall,at his own expense,Mdhwllh remedy,raptor,correct,repla of cause to be remedied.repaired or replaced
such damage or such dead In materials or workmanship.The loregang warmatles shall survive any inspection performed in connection with the agreed upon work.
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for t e [um of:
Payment to be made as follows: dollars($ J 'OD )
Remove ell job trash
O
All gal fees on all products from manufacturer.
($ l upon signing Contra p\-gyp/T Add permit co If neatletl we pull permit.
%i$�l upon completion of�/ No No regime for ho a improvement contracting work shall require a
do paym edva ce dap sit)of more than one-third of the total contract f
%($ )upon completion of oil r the I am nt of deposits or payments which the contractor must
ma 'n o ce,t order r otherwise obtain Mail of ape 'al oNer
($ )shall be made forewarn upon meter so equip ant
wmptetion of work under this contract.
N.I.'.This .Pa.'may be wAMrewn W us II not accepted vnran days.
dxe e i r
Acceptance of Proposal I have read both sides of this document and JAANY
ri s,specifications and conditions stated.I understand
that upon signing,this proposal becomes a binding contract,You are authorized i dspecified. Payment will be made as outlined above.
You,the Buyer,may cancel this transaction at any time p o ight of the third business day after the
date of this transaction.Cancellation must be done in wri in
DO NOT SIGN THIS CONTRACT IF THE BLANK SPACES.
Sl9nawre Data 1 `ol J sigma. Dale
IMPORTANT INFORMATION ON BACK 7