12 VICTORY RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
W
Massachusetts State Building Code, 780 CMR SALEM
Revised,Nar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building P it Number.
t
Building Official(Print Mine), Date
SECTION L SI NFORINIATION
I.I Property AdtJryss:, _ ['lza 1.2 Assessors Map& Parcel Numbers
I.1 a Is 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 It) Frontage(R)
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:
Zone: _ Outside Flood Zone?
Public El Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Own a� icord:
A
�hme(Print) City,State
No.and S[ree[ tTelephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all t at apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_J Other ❑ Specify:
Brief Description of Proposed Work':
SECTION d:ESTIMATED CONSTRUCTION COSTS
Itc Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee:$4L Indicate how fee is determined:
2. Electrical S ❑Standard City/Town App ication Fee -.
-"' ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
d. Mechanical (HVAC) $ List: .
5. Mechanical (Fire Suppression) $ Total All Fees:$
Cl-Check No. Check Amount: Cash Amount:
6. Total Project Cost $ paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction up visor License(CSL)
License Nw" n'ber Espin ton to ^
Namc of CS i tic[der
List CSL"type(see below)
No.and Street Type Description
_ ,^�— U Unrestricted2 Family
(Buildings u el ing cu. R.)
A t �h �Ll( J�X� R Restricted I&2 Famil Dwelling
Cityrfo ZIP -r— M Pvlasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Teo hone Email address D Demolition
5.2 Registered Homeja4vovemen trac r(f1IC)
HIC Registration Number Expi at" Dat
IIIC Com m e [ gi r Name
No. and tr et Email address
Cit /Town,Star ,ZI 'Fete hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G:E,.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§uance 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
't4 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nane(Electronic Signature) Pate
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest unde a pains and penalties of perjury that all of the information
containe this ap 'ot is true and accurate o t Jof n kno% edge and understanding.
R
Print Own d 's o Authorize ent's Name(Electron ignature) 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 bLG.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.i>ov/ort Information on the Construction Supervisor License can be found at www.mass.^ov/dps
� 2. \Vhen 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"
CITY OF S:1L ams %LAtS&: CHUSETTS
i BUILDING DEPARTMENT
120 WASH .IYGTON STREET,3-FLOOR
T EL 978 745-9595
F.+x(978) 740-9846
KI.NfBFRi EY DRISCOLt
MAYOR TTiObtAS ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BuiLOLNG CONMISSIO.)ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A i Iicant Information Please Print Legibly
Natlic(Business,OrSaniratiory Individual):
Address:
City/State/Zip: Phone#: �2 1C.�e l
Are yo employer?Check ijl"ppropdate box: Typo of project(required):
I.FXI am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-conlractorx
2. ].am a solo proprietor or partner- listed on the attachod sheet 1 7• ❑Remodeling
❑ P P P These subcontractors have 8. Demolition
,hip and have no employees ❑
working,for me imam capacity. workers'comp.insurance.
Y9. ❑ Building addition
[No workers'comp.insurance 5.0 We are a corporation and its
ired.)
re9 a
officers have exercised their 10.0 Electrical repairs or additions
. .
).ElI am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp, c. 152,01(41.and we have no 12, Ifre
insurancareyuired.)t employees; ❑ ��
comp:insurance required.) 13. Other,
-Any appiieum that ehocln box Nl must also fill out the section blow showing their workesa•cempeasaion policy inf[smatron.
'I hvneownns who submit this affidavit indicating they ate doing all wmkand than him MISideconimctart must submit a new,affidavit indicting such.
:Contnuton that choak this box must artachod an addiduml shoal showing the name of the subcootractere and their wurkero'comp,policy Infomsatioe.
tam an employer that is pravlding workers'compensation hrsurancefor my employees: Below Is the pollo and fob site
infornrathus,
Insurance Company?lame:.
Policy 4 or Self-ins.Lic.H: Expirdtian Date:
Job Site Address: JT `e g i�1� City/State/Zip:
much a copy of the workers'compensation policy de laf rattan page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOIL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 und(or one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a line
Of up to S230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Oftice of
y, Invcsligmivas ui the DIA r ins once covemga verification.
Ida hereby certify ur er the fula t oar erruhl ofFeefury that the h1formutlmr provided ub Vol s i ue and correct.
�',• -- ),to:
Phoned:
Ofriciul use unly. Do not write its this area,to be canipleted by city ur town gJirlal
City ar Town: PermiU7.1ccnse k __
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/fawn Clerk 4. Electrical lnspector 5. Plumbing Inspector
6.Other.--
Contact Person: __-_. iF.
[
CITY OF S.U1 E\d, 1NTLkSSACHUSE-M
• BL:mDL\,G DEPARTMENT
B 130 WASHIINGTON STREET, 3'FLOOR
TEL (978) 745-9595
FAA.(978) 740-9846
R D
KIN
iBERISY ISCOLL
MAYOR D THO.%W ST.PtERR&
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CONWISSIONER
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 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of haulerl
The debris will be disposed of in :
(name of facilit )
(address of facility)
i
s1 nature of rnut applicant
i
date
dcbrisatf dux
V�s5acl�usefts - pepartrnz:rrt'ot Public safey
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�a�` OME IMPROVEMENT CONTRACTOR
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i`Reglstmtlon: 161323 Type:
pi ration: 10/142014 DBA
CRAIG WINDOWS
LHU�MNCTON, MA01050
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ACCORD:S.Sf7410 8'(mv�{dLCYR:IL
- 63sra,+OP9a`G'ORD COhPppA270>.Ap xisylar�,d.
WOOnext Step lining
home efficiency,mace eery _
I I
Tuesday,June 11,2013 l V/ WIC
i r
This Agreement is entered into on the date shown above and is by and between Darren Cloutier having a
mailing address at 12 Victory Rd Salem Ma 01" (the owner')and Next Step Living Inc.,21 Drydock
Avenue,Boston,MA 02210("NSL'
1. THE WORK AND THE MATERIALS
NSL shall perform all work and supply all materials described on Exhibit A'(*Next Step Living window,
proposal)attached to this Agreement and will be responsible for any and all equipments,supplies and
aPpurtenant items as may be required and necessary to Perform all work described on Exhibit A and any
performance reasonably inferable from it,including clean-up associated with NSL's work(the"Work").
2. CIIANGES1pERFORMANCE OF THE"WORK
2.I NSL will not make any changes in the Work other than those described on Exhibit A.unless agreed to in
writing by the Owner.
2.2. NSL represents and warrants to the Owner that(a)the materials and equipments furnished under this
Contract will be of good quality and new,(b)that the Work will he free from defects,and(c)that the
Work will conform with the description of the Work described on Exhibit A.
3. TIME FOR PERFORMANCE
NSL shall ensure the Work will be done in a timely manner and will ensure that the Work is done diligently
without delays or interruptions until completion. If the Work is to be done in stages,the previous sentence
shall apply to each such stage.
4. larrms of pavmenL
The Owner shall pay NSL the balance upon the completion of the Work described on Exhibit A.
S. INSURANCE AND LICENSING
NSL represents and warrants to the Owner that NSL is validly licensed and that NSL has all insurance required
by applicable law and normally maintained by prudent contractors in NSL's field,including,but not limited to,
workmen's compensation for all employees who will perform the work.
6. QUALITY OF WORK
NSL agrees that the Work will be performed in a good and workmanlike manner,and that NSL will ensure
repair and replacement at its own expense,and promptly upon Owner's reques14 any defects in workmanship
and materials provided by NSL or subcontractors of NSL which appear up to(24)months after the date of
final payment for the project to NSL or within any longer period as permitted or required under applicable
law.
7. GENERAL PROVISIONS
7.1 Any disputes which may arise between the Owner and NSL shall not impede or interfere with the diligent
Performance by NSL of the work.
7.2 This Agreement shall be construed in accordance with the laws of the State of Massachusetts.
21 Orydock Ave 2n°door, Boston, MA 02210
Rhone: 1-866-867-8729
www.nextstenfivinci.com
R Or
next step ( ing
home efficiency,mad easy
I
73 NSL may not assign this
consent. AV,or any of its rights to Payment without the Owner's prior written
EXISTING CONDITIONS Bc PROPER Y PROTECFION
&I NSL shall not be responsible far any damages as a cnsequence of the Work Pormed in the h
Pre�stmg&s rottiu swood a lms m,,�,dn hvt are not limited to e:acica3 or broken �0e due
Piped and fittin g ,faulty electrical wirin &Ywall,old
8 2 NSL reserves I t�right t to perf
or.the r uPon the discovery ofasbestos,mold,or any other potential
is health risk
1 for services shall be responsible for removing the hazardous materials and all bills
83 NSL will make 1>fl!d immediately. Work cannot until remediation is complete.
best efforts to Protect any Property of the customer,but it is
to remove or Protectcustomer's responsibility
including dust protection,any personal property the including the home itself NSL
will not be respcnsble for damages to or losses of and of the above mentioned property not properly
Protected prior to the commencement of work:
9. PAYMENT
Customer
9.1 TOW
»"ad final Payment t of $)will be duel Pay I13 of estate amomit,or($),upon acceptance ofthis
imate
9.2 Total
$2,04096 amount is(�221.Q0)If customer is usmgii financing.$99.00 deposit due at signing,&
aPProval,and final payment of($4,pg 134)will be due upon completion.
This Contract,including the documents incorporated into this Contract;forms the co
between Contractor and the Owner. The parties re 'he and warrant that in ex Mete integrated agreement
relying on represent�ns other than as expressly contained herein These are no otherg�Contract,they one not
forte a binding agreement between the Parties other than this Contract and its ineo terms or ants. that
C°ntrect suP�edes OR Prior agreements between the Owner and rPorated documents. This'
ran
not be
ered absent a
they uunderstand and agree to j all term harem,sequent written agreement signed by both Peres Both Parties hhavte ieviewedm�Contract tand represent that
We have read this Contract and agree to its terms.
8 er -
/ Next S Living
1
Signature
Signature
Date
Date
21 Drydock Ave 2nd floor, Boston, h4A 02210
Phone: 1-86r3-g67-8729
www.nextsteolivinn.com —