37 VALIANT WAY - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building� Code, 780 C SALEM M&EIVE�D�Qw LIE
Revised Mar 2011
4 Building Permit Application To Construct, Repair. 14001�e4trdli�L a
One- or Two-Family Dwel ing
This Section For Official U
Building Permit Number: Date pplie
4.,
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Propert Add r s:��,, II 1.2 Assessors Map& Parcel Numbers
T1 �l l�+'17 Lo
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
c �A1�
Toning District Proposed Use Lot Area(sq FQ Frontage(n)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G 1.a 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Ow er'o((Record:
011&riIn Im r-4to�i5 rJc l�PVYI, �Y)1 6l�l7a
Name(Print) V City.State,ZIP
& 1 -7 -80-3- 11 "
No.meet Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other b Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building 1. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical g ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ i 2. Other Fees: $
4. Mechanical (HVAC) $ List: � �,�_._S_,�)
5. Mechanical (Fire i
Su ression) $ Total All Fees: $
n ^�6. Total Project Cost: $ Check No. Check Amount: Cash Amount:
o(o( ❑ Paid in Full ❑ Outstanding Balance Due:
M��Lti�j ttJ�`1
SECTION 5: CONSTRUCTION SERVICES
5.1 Co s ruction Superv� (3
r 'eense(CSL) _
ai9 3 r� 3
lac �[ f License Number Ezpirau n Ua[c
Name of CSL Holder
- List CSL Type(see below)
No.and Stre �"�<J Type Description
I�A oig7o R Unrestricted(Buildings u el ing Co. fl.)
R Restricted I&2 Family Dwelling
City/Town, Stag _IP M Mason
RC Rooting Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
Q-19 - 53�-'7t71 I Insulation
Tole hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ,q e6 r ' l0 1
r OO
HIC Registration Number Espuation Dale
HIC.Com /my-Nr`ame a I
a ill Re,i- ant Name
No. a dStrre t 1 ' A /
E
c� b> I� mr3al� z� 6l7-3Sy�946 m ai dress
City/ own,State,ZIP 1 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: OWNEIYAUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property, hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Prith Owner's anw(Electr iic 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.
�l�r�r /1Agn0 e _
Print( rncr's or uthonzed�gcnrs 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.eov/oca Information on the Construction Supervisor License can be found at www.ntass.yov;4d
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"
� �\, trre a.,untnnrrrrveutrn od rveus'a'ucnuseus' I-�� -
-a Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
t Boston,MA 02114-20,17
www.ntass.gov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lel4ibh'
Nanle (Buciness'grgmtirationllndiwidunl): �iC.hae) �� J 11��
Address: Ed
City/State/Zip: U (} ON ) Phone4: 17� 6 -717�
Are you an employer? Check the appropriate box: Type of project(required):
i.❑ i am n employer with _ q. El am a general contractor and I
un Ioyees (full and/or * have hired the sub-contractors 6. ❑ New construction
p part-time).
2. lama sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractor, have
i I S. ❑ Demolition
working for me in any capacity. employees and have workers ) ❑ Building addition
[No workers' comp. insurance comp. insurance.'
required.] 5. ❑ We are a corporation and its I [j Electrical repairs or additions
:.❑ I am a homeowner doing all work ofticers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.El Roof repairs
insurance required.] c. 152, §1(4), and we have no
employees. [No workers' 131 Other_`
comp. insurance required.]
'Any applicant that checks box 4 1 must at so till out the section below showing their workers'compensation policy information.
' homeowners who Submit this affidavit indicating they are doing all work and then hire outside contractors must.ubmit a new affidavit indicating such.
^Convmacns that check this box must attached au additional sheet showing the name of the sub-contractors and srnte whether or not Ihosc entities here
employees. If the sub-contractors have emplovecs.they must provide their workets'comp_policy mtmber.
i out an enrphgyer that is providing workers'compensation insuranee far my employees'. Below is'Iire police and job site
information. .
InAll'9nce Company Name:_
Policy .-.'-or Sell=ins. Lic. #:_ Expiration
Job Site Address: 3� n,k City/State/Zip:_ �� Mf3 b►4"lU
Attach a copy of the workers' compensation policy declara on 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 S 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 S250.00 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 certi ,rtn er Ike gains rant Imnallfies ofperj7r ,that Cite ittfornratiort piwi itled ahore is trite and correct.
Signature: Date
Ojfrcial use only. Do not write in this area, to he couilVeted by city or town official.
City or Tory n: Permit/License#_
issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk q. Electrical Inspector 5. Plumbing Inspector
fi. Other
Contact Person: Phone #:
U
--- t�YOffi<r u(Ceaw mer Affairs C Repiee55 Regulation License or registration valid for indieidul usr nnlc
` . HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Re-ulnut.,
Registration: 148688
•. Expiration: type to ton. IA 0 -Suite il;n
P t0/7 8129 7 5 Supplement�-artl Boston.NIA R2116
LOWE'S HOMES CENTERS INC
RICHARD CHALONE136 �
TURNPIKE RD,SUITE 700 ...c..-.. 8.:.�. IC SOUTHBOROROUGH, MA 07772
Undersecrciary Not valid without signature
Massacnusevs - --epar. e
Board o! 3acas-g Regwarc,s a c
C tinn Super>E
-ce-se
cease CS-082193
MICHAEL T DEMILLE
5 BRISTOL ST
SALEM MA 01970
20: 4? HP LAS,EA.JET FAX
n.01
CERTIFICATE OF LIABILITY INSURANCE DATEIMM.4IDYYYY)
101'24f2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. a
IMPORTANT.1 ortincate holder Is an ADDITIONAL INSURED,the policy(las)must be endorsed if SUBROGATION IS WAIVED,subject to the
terns and conditions of the policy,certain poiicios may require an endorsement.A statement or.this cortlflcalo does not confer fights to the
Certificate holder In I;eu of suCh ondorsor
PRODUCER
c cr Brenda Cozzollno _
E A Knley No. (401)709-83',k6 ��_.m v (AQO)370-2924
450 Veterans Memorial Parkway Witt" brendacocakeiley.com
Building 5 naoauc 163601 —� —_--
East providence RI 02.14 1.
:NS• FRIT,1AFE ppiQDitVERAGE F--„ Nk;c�
NS fta0
MC CMxtrudiw IMSUA_R A: AllAntic l7asuahy ins Co I42846
MSUr1eR B:
5 Bristol Rd '—
WSURERC:
auum:Ra: __
Salem MA 01970
COVERAGES CERTIFICATE NUMBER: NUMBER:
THIS IS TO CERIIFY'.HAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO ISE INSURED NAMED ABOVE FUR IHE POLICY PERIOD {
INDICATED.NOYWIT14STANONG ANY REQUIREMENT,TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TU VMMICH THIS
r PPTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEDHEREIN IS SUBJECT TOALL THE TERMS.
xcw I�ZAN n) Drclous of s�Vyj, t I• rs sfiQy 1� nt veBEEN RFDUCFD BY PAID t I s.
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C3r,)anW Contractor.
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CERTIFICATE HOLDER CANCELLATION
Taan oT Middlctcr SHOULD WRY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPRtA71ON DAT'B THEREOF,NOTICE WILL BE OELWERED IN
)05 North rdaln SrOet ACCORDANCE WITH THE POLICY PROVCI0 F, i
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AUTRGfaYRa RMeRBteNTAn� ���
Middleton IAA 01040 Ka.tner?ne M. j"e-1 rey, AA1y CIC
to T989-Z009ACO�RO CORPORATION.All rt.lnts mserved,
ACORD 25(2000I00) The ACORD name and logo are registered marks of ACORD
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L"c. INSTALLED 3 SPEGNLIe NUMBER CUSTOMER '`'
STORE NO. .".... S - DRESS -....- .� .'Y t�STREET ADDRESS
OITY\\ STATE LP Yre`L'�, CRT - STATE LP
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TELEPHONE 1s TELEPHONE -
97�-69 o Na, -
GATE //// LOWES CONDUCTOR LICENSE NUMBER � cesx 24 LaZu REO ,.
Tli¢ N a mrwrw ub mmN"epd iervtces Pamea IWbx'ltm rowna7asaa'aa�sal�mr Ian T+ai^���uwn Parre4d met�n �m nw..uro uw srev .mMecea w u :
aowmam areT Nm-,camoon.oaaaaa.wm mhd In,B:erxmh .Ad3aaa.?ne alMo.ae nn.rem-alNn ca,x lred m'fierem cob•colmae._.
PIFRSE REPD PIL TERMS ANOCONOpION3;ON THE ESl0f!OFTHIS PpGEANO PoLLOWING PgGE$BEFORE51GMN6t y "' -.Z
` INSTALLATION STREET ADDRESS c1 CITY STATE ZIP
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Contract Total
'applicable taxes included
NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamphlet Renovate Right By signing this Contract,Customer
acknowledges having received a copy of this pamphlet before work began Informing Customer of the potential risk of the lead hazard exposure
from renovation activity to be performed in Customer's dwelling unit
NOTE:If rotted wood is discovered during installation additional charges will apply.You will be given a quote and a change order
must be completed and at ned by the customer for any additional charges. Customer must initial.
•Any work at material not specie Is not included In mis contract.Any changes or additions will he M an additional charge for the material and labor.
PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees the right to take photographs of all work performed at the Premises related to this
Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,woddvade,in perpetuity.
Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically, and agrees that Lowe's may use such
photographs for any lawful purpose, including, but not limited to, marketing,advertising, publicity, illust alion,training and Web content. By initialing
here,Customer agrees to the foregoing. (Customer to initial to the left(.
Work is to come cc upon reasonable availability of Contractor and/or any special onj or c stomer made Doodle)which is anticipated to be
rl$�fe1;.� / [fill in date].Estimated completion data Is / �{r/�[fill in date].
mated Said est subs mial completion,data is not of the essence.A statement of any contingences that would materially change said estimated substantial
completion date is as follows: ,
(if applicable,insert a statement of such contingencies).
This Contract provides that all claims by Customer or Lowe's will be resolved by BINDING ARBITRATION.Customer and Lowe's GIVE UP THE RIGHT
TO:GO TO COURT to enforce this Contract(EXCEPT for matters that may be taken to SMALL CLAIMS COURT).Lowe's and Customer's rights will be
determined by a NEUTRAL ARBITRATOR and NOT a judge or jury. Lowe's and Customer are entitled to a FAIR HEARING. But the arbitration
procedures are SIMPLER AND MORE LIMITED THAN RULES APPLICABLE IN COURT.Arbitrator decisions are as enforceable as any court order and -
are subject to VERY LIMITED REVIEW BY A COURT.FOR MORE DETAILS:Review the section titled ARBITRATION AGREEMENT,WAIVER OF JURY
TRIAL AND WAIVER OF CLASS ACTION ADJUDICATION found in Me Terms and Conditions of this Contract. -
DO NOT SIGN THIS CONTRACT UNTIL COMPLETEAND YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON ALL
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 ALL PAGES OF THIS CONTRACT.YOU ARE ENTITLED TO A
COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE.
WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS 'Al DAY OF ../�r 1•'�r��-t'r ��' -
Lowes Home Centers, Inc. f 1
i ,
t Ow6r ..�
Specialist or Above. IZ I Co-owner or Witness'
Customer acknowledges receipt o/a We copy of this contract which was completely filled In prior 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.Sea the attached notice of cancellation
form for an explanation of this right.
«��• eilc rnov oaxw MLcwa'aa Lowe'a aria u,e gaela cosies