4 SUMNER RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Wv�)` Massachusetts State Building Code, 730 CMR SAL ElI
Revised.t(ilr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only .
Building Permit Number: Date, plied: l 1- 13.
;,n !/ /y
Building Official(Print Name). Signature -. Da e
SECTIOyy 1:SITEINFORNIATION
1.1 Property Ad r ss: 1.2 Assessors blip& Parcel Numbers
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(If)
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? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION2: PROPERTY OWNERSHIP"
2.1 Owner eca d:
9v
pme(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check. that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units er ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and blater'als
I. Building $ I. Building Permit Fee:$ Indicate how Ice is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
1. Plumbing S ?. Other Fees: S
4. Mechanical (FIVAC) $ List:
5. Mechanical (Fire
Su ression) Total All Fees:S
Check No._Check Amnllnt: Cash Amount:
'r(>. otal Project Cost: S _ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Constru n Supervisor case(CSL)
License Number Espira on ate
Nance of CSL Iloo
List CSL"fype(see below)
ram, A�
No.��treet 7` Type:- Description
C I U Restricted
1 L3ui Family
s u el ing cu. R.)
R Restricted I&2 F:unil Dwelling
Citylfown,State,Z P M Masonry
RC Roofing Covering
WS Window and Siding
SF SOlid Fuel Bunting Appliances
L Insulation
Tole wn—C'� � e' Email address D Demolition
5.2 Registered Home Img;ovemen Contr, r(HIC } �
Y) HIC RegistrationGs va' n U,ue
Iu me-r Name
No ands Email address
ll/-I a� -1� V� A
Cit /Town, State,ZIP "role hone ✓ -
SECTION 6:WORKERS'CONIPENSATION 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 Is�uanc 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
I,as Owner of the subject property,hereby authorize !F� ��t1HCf
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION
By er " y name below,I hereby attest u er the Veof
sandenalties of perjury that all of the information
con ained in its ap ' true and occur to to thekno vledge and understanding.
Print( vne 's or Authorize)Agent's Name(Electronic, ign,turef ,to
NOTES:
I. An Owner who obtains a building permit to)To 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 NLG.L.c. 142A.Other important information on the HIC Program can be found at
ww%v.mass.gov.'oca Information on the Construction Supervisor License can be found at wsew.masssov!J.tLs,
2. When substantial work is planned,provide the information below:
Total floor area(sq. ftJ (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. Total Project Square Footage"may be substituted for"'rota) Project Cost"
L
�V...v PLEASE READ THIS •M�•
try Sold,Furnished and Installed by:
Branch Name:Boston North 6 South Date:DIb W THD At-Home Services,Inc.
d/Wa The Home Depot At-Hone Services
Bram:h Nmnbev:31 mW 33 908 Buxton Turnpike,Unit I,Shrewsbury,MA 01545
Toll Free 877-903-3768
Pederai ID#75-2698460;ME Lic#C 02439;RI Can Uc#16427
Cr tic#HIC.O.%5522;MA Hmhe Improvement Cuntraetu,Reg,#126893
lout atitm Address: _� Suf,Yl!'ler f M Ina, [J1G?0
City State zip
Purchoser(s): Work Pheme: Horne Ph": C.11ph"..
i [ ] R161,305-05
Home Address: _
(If different from Installation Address) City State Zip —
E-mall Address(to receive project communications and Home Depot updates):
[]1 DO NOT wish to ructive any marketing emails from The Home Depot
- Undersigned(*Customer"),the owners of the property located at the above installation address,agrees to buy,
an P one Services,Ina(`The Home Depot")agrees to famish,deliver and arrange fo•the installation('TBstallaCidn")01
all materials described on the below and m the rcfu enced Spec She et(s),all of which are incorporated into thisContract by this
rutcrence,along with any applicable State Supplement and Payment Summary attached hcnxo and any Change Orders(collectively,
..Contract"):
i
Jub#: Window ucls: 3 Sh s)#: P ' R t
Reveling Sitting s 0 insulation
72Cby ? ❑Gmtws/Covers ❑Entry Door
Routing Siding Windows Insulation
" ❑Gooier/Come (]finery Doors ❑ $
Rohfing LjSidi.g Ll Winduws U insulation'
❑Gutters/Cov r ❑Entry Doors❑ '-.. ' $
Roofing LISiding 0 Windows El Insulator "'--
❑Guners/Covers ❑Entry Doors fl $
Mirrimum25%i Deposit Of C;sedg dAmamt due upunai wtdw of this remnant. Q
Maine PnMamxetnmy ant depositammtbati me•Wird ulthe CamractAmwloL •Tdlal Contract Is V�,
Customer agrees that,immediately upon complerion of the work for each Product, Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and pay my balance due. As applicable, each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or tefatinate this Contract or any individual Product(s)included herchh,at
its discretion,if The Home Depot m its mthoimd service provider determines that it Cannot purf"urm its obligations due lu a structural
problem with the home,environmental havards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because
work required to complete the job was no included In the Contract.
Payment Summary: The Payment Summary# B26g9$ . included as pan of this Ceattaul, sets forth the total
Contract amount and payments required fir the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER .
You are entitled fins completely filled-in copy of the Contract at the time you sign, Du nut sign a.Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by Individual spec Staiets),before work on that Product
Is complete. ..
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by The Hone Depot or Authorized Service Provider throut(h the data of termination,plus any other
amounts out forth In this Agteement or slowed order a Herohle law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE BOMB DEPOT PROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THY.HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Ae mhorizeflon: Customer agrees and understands that this Agmroent is the entire agreement between Customer
and The Home •put with regard to the Products and Installation services and supersedes all prior discussions and agreements.either
=1 ter written,re ring to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed
by stod
mu Depot.Customer acknowledges and a�cca that Customer has reset,mdcrswnds,voluntarily accepts the
t of a ewpy of this Agreement.
e h (� sot - ed hyi,. lo./r�7'(s
me Date Sales onsultant'sgt�e Date
X Tel hone No.
Cusmme:r's Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS (m appllwble).
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DFLIVERiNG WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
sPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
Nlrr7CE:ADDITIONAL.TEId113 AND C0NDr'1'IONS ARE STATED ON y'HE 9AVERSat SIDE ANI/ARE PART OrT 1a CONTRAC[
06-04.13 Where-Branch File yellow-Customer
90/10 39Vd 1-Od30 3NGH 1019EL9L19 60:L1 EIOZ/10/11
� 5 CITY OF S�1L.EM, 1 WSACHUSETI'S
t tl BI:=w;DEP.Aftn NT
120 WASHNGTON STREET, 3" FLOOR
TEL (978) 745-9595
F.ALX(978) 740-9846
KI\IBERL.EY DRISCOLL
�L�Yolt THOswST.Pm m
DIRECTOR OF PUBLIC PROPERTY/BCILDI,IIG CONNI5SIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
u
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of NfGL c 40, S 54;
Building Permit tk is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as de6ncd by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
'fhe debris will
be disposed of in
(nnmei it �--
--_— address of facility)
S'sn Lure ofpermit applicant
tat
Ivhn>ail'dx
' t l,lassachusetts -Department of P + l a ctv
- Board.of Building Regulations and srwt arr s
L irense. CSSL-099699
i
172 WHALEINS LANC
Commissioner
02J0813018
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Are yo air employer? Check the , pr opriate boar 1I ��pe�of pt o!ect(r equ.red!
I-i 4. Iara "�en ral r❑•ic a aru t.
I1 ,eaa. employer�nh-�l�- - - c- INN �t ,s _cien I t
emglepees(iu1l and/u a c:trme).` have hi- d tre srh cnntr cars
--� I P�_nx dcl:n�
am a soleptop'i w a nanne!. tist..t on th :Itiche-d tl yet I LJ
shtp and have no employees Th s sut on r, rnrrlraee ElD no'ri n t
o:e <errpl and ave":o k.-I, I
worl ing i w me in an; capacity,
❑Put tt 'tdd I i
o workers' comp insaralce com— n sl an I r.,_
egmled
L - a a orroranor and its 10 J r l t t tl rip , s c doiticris
l aro a romeo r t e .lc r�aL' worl..
rffir ;s have elerclt d them j_f"r:n 1 n- ep rrs o a .dumne
` of e nation p M I 1 .❑Ron air--
msel+. [ o wo+ee s canto.
._e.. r„d )i 1�1. r}1!1 rrd we h :. n:, I _
..' Comb. ir5'JMnde required.] i
Am,apphe;uuFm mec4sln'kl t unaLs�ill ou the mnnuu clnw shore,t- la or6e ritp :cn nn rrl ' .fn 7.�tn. -
i 1-i^.menwners who su- } a7ida'•i.:r.dica r^tr y a.z dn,n_all wc: ;,,.t tier n,rii uu.r:..•Onl.�'.nr. r v a.f Ra n �: ril:m ra- �:,n psi:d;. I
'Cnnrrnanra that check thii hna must nma ed an additional sheet snou�ir.e the name m the suh-cca:rannr.,mA state whe.he- or nw �nsr ni a . have
mn!ov_es. tf tnz su'o-ecnt a rers hav, thv r-t�c;rrmid6f,ret .-o l Comp pelic}mtnrh: j
T nwo tin cntpinper the is pru�tdutg-x orLa:s' t n.ce(o nr,'empiohees BChm=isTire pnli r mrrljun site
compensuito uesu a
in(orrnadon.
Insurance Companv Name.11oli,v al
-- /
Solt -lic,�: `�' .. &:� P_ p:rapon Data.
iroSiteArdlss.__ -cf�- �- _ - -C.tt 'at1t...'.rp
Attach a copy of the workers compensation policy declaration page ishoming the polio;number and r,pr-ation datci. i
Faiiure to secure cova agt as Teyu;rd under Se tr n ^_SA of IN!GL c. 1 2 can!dad to fi mpoanon of c rinina! p raifleto`a
fine un u:S1 300.00 andior one- eai imprisonment a:well as civil p:. allies in th:.,r,rm of e STOP FrORI.ORDER an i a fine
of uT to,S'"50.00 x d a_�;r. pit?]a[or. Be adrt_;dc dl.l aj - p;' of 06,,a�atern rt may ba forvardeo u: tr �rrt.ce m
]n eti^?tidn6 of 01::61A I r n it i:c: CM
I do herah} cardfr under Ire pacrt d�arratii f perjnn that!the i.ra(ornati.nr provided a6nve is true and en rcct. -
Pholic
litre nnh:, _Do not Nrftc it' this area. to be conzpletec hp cm,or.tm,�n official. I I
ICity or Town: Permit Ucense 4
Issuing Authority tcircie nner. - -
1.Board o`Eealth 2.Buiidin_Department 3 CityiTown Cicrk 4.Electrical inspector z Plumbing Inspector
fi. Ofner II
Phone#:
Coniact Person:
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