6 WEST CIR - BUILDING INSPECTION ' f
The Commonwealth ofblassachusettNSPECTION.AL SEF ViCE�TYOF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 Cl�({(t APR 2 3 A Oi+ed Mar 2011
Building Permit Application To Construct, Repair, Renovate
',Or Demolish a
One-or Two-Faintly Dwelling
This Section For Official Use Only
I Building Permit Number: Date p iedt
in 4, ' ° 5
Building 011icial(Print Name). - Signature• Da
SECTION I:SITE INFORNIAT10N
(� 1.1 Property Address: / t , \ � r 1.1 Assessors Map&Parcel Numbers
!� 1.1 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(It)
1.5 Building Setbacks(ft)
Front Yard Side Yanis Rear Yard
Require) Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ — Check if es❑ P y
SECTION I: PROPERTY OWNERSHIP,:
2.1 Ownertof Record*
hrYS M°s- q-7b
Ante(Print) d City,State,ZIP 0363
L C,�� �� 1� �3
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ t r of Units Other ❑ Specify:
Brief Descr tionofProposed o
' f� acP
v a VI
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ S '7 I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2, Electrical $ ❑Total Project Cost"(Item 6)s multiplier s
J. Plumbing $ P 9ther Fees: $
d. Mechanical (FIVAC) $ List:
5. :Mechanical (Fire $ Tahnl All Fees:$
Skip ression) -
p� Check No._Check Amount: Cash Amount:_
6. Total Project Cost: $ / ❑Paid in Full ❑Outstanding Balance Due:
l�c� I t_><,0 W WIERT 5-rep S 1 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supevis Lice me(CSL) b a 3 6 y` P (o
l>f:e Tr- Je N lic, G, License Number E.vpiration Date
Namc ufCSL 1 Id I
i l List CSL'fype(see below)
Type - Description
No.and Street .
I- M G r U Unrestricted(Buildings to 35,000 cu. It.)
�')G1,11So� V v 1, y��l�1 tip
Restricted 1&2 Family Dwelling
City/Town,State,ZIP bl 'Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel[fuming Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Homglmproovem t Cant f:'cloq(HI � � �� ( t �V 17
V HIC Registration Number Expiration Date
HIC C p+hy Nmt •or HIC Registrant Name
" � e�ov� ,l/� f5�� �� 06(o g67- ?� Email address
City/Town,!Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.QL.c. 15Z.$25.0(o).
Workers Compensation Insurance affidavit must be completed and submitted with this application. Fnilure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
IAPPLIES FOR BUILDING PERMIT p
1,as Owner of the subject property,hereby authorize /V �� I 's f Fl 1
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
5 �- t oon��&f y- Z6 - r�'
Print Owner's Nmne(Electronic Signature) Dale
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
Dy entering name below, I hereby attest under the pains and penalties of perjury that all of the information
cauained m is applicatin a and accurate to the best of my knowledge and understanding.
y- zo-
Print Owner's or r uthordzc-d Agent's Name ''ecuonic Signature) Date
NOTES:
1. 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(111C) Program),will nit 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.nms�,ov/dps .
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_
f "Total Project Square Footage"may be substituted for Total Project Cost"
Permit Services 401 246 2868 p.4
The Commomvea&h ofMassachuse is
Department oflndustridAccidents
0)7ke of Investigations
I Congress Street, Suite 100
Boston,MA 021I4-2017
tvww.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/EleetdciansJPlumbers
ApplicautInforniation Please Print Leeibly
Name(Business/Organization/inditdduai): Next Step Living -
Address: 21 Drydock Ave
City/Stale/Zip: Boston, MA 02210 phone#:(866)867-8729
Are you an employer2 Check the appropriate box:
850 4. I am a general contractor and I Type of project(required):
1.® I am a employer with ❑ g
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
shipand have no em to es These sub-contractors have
P Yc 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance t 9. ❑Building addition
required.] 5. Q We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.f]Plumbing repairs or additions
m self. oworkers'coro . right ofexe tioa erMGL Y R'r lnP P P 12.❑Roof airs
insurance required.] t C. 152, §l(4),and we have no
employees. [No workers' 13.ff Other 1RC Q. man
comp.insurance required.] ;yid wr
"Arty applicant that checks box pl must also fig out lhesection below tltmvittg their workers'compwmtianpolicy iofomalion.
t.11ommuncrs who submit this affidavit indicating they me doing all work and than hire otusideeonnadom must submit a nee.affida•it indicating such.
lContraemrs that check this box mast attached an additional sheet showing the name oftbe cub-contractaua and an%whether or not thole amities have
employees. if Ole attK(Imrselors have employees,they must provide their workets'wrap.policy number.
I ant an employer that is providing workers'compensation insurance for my employees: Beloiv is theper icy and job site
information.
Insurance Company Name: A.I.M Mutual Insurance Company
Policy#or Self-ins. Lic.ti-AWC-400-7030025-2014A Expiration Date: 9130/15
Job Site Address:.. (1-L �� `City/State/Zip- 01 I L/V\
Attach a copy of tire workers'compensation policy declaration 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fore
of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
lovesttgations of die DIA for insurance coverage v G lion
I do hereby cert&tinder the pains and pe es perjury that the information provided above • true and Correct
Si azure: Date _ @ V `-15
Phone#•��(n����"�t�a�
Official use only. Do not write in this area,to be completed by city or town ofefal.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Citylrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone M
office of Consumer Affau4s and Business Regulation
10 Park Plaza - Suite 5 170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 162111
Type: Supplement Card
NEXT STEP LIVING INC. Expiration: 1r1412017
ROGER OUELLETTE ---� -- --- ---
21 DRYDOCK AVE. 2TH FI_ -------- __----
BOSTON, MA 02210
- Update Address and return card.Mark reason for change.
^. Address Renewal - Employment L Lost Card
7hv [•-r..rrva.ntucnlK ..r•.. r(:ra:nc rudil�.
Office or Cansumcr Affair&Rusiness Regulation License or registration valid for individul nse out y
NOME IMPROVEMENT CONTP.F4CTOP. before the expiration Elite. If found return to:
Office of Consumer Affairs and Business liegulation
-- Registration: 162111 Type: 10 Pane Plaza-Suite 5170
- Expiration: 1J1412017 Supplement Card Boston,MA 07.1IG,
NEXT STEP UVING INC.
ROGER OUELLUTE
21 ORYDOCK AVE.2TH FL ---
BOSTON.MA 02210 {;ndersecremry --- --`tiot'valid 1vi4hout signature---------
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GREGORY P OFS'FF:NANO. ;
121111,1,S'I'
Hanson MA 02341 #='
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STAR .ENERGY
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VINYL OUBLE HUNG
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Cnnaa Double Gla ing.Argon Fill.Low E
ENERGY PERFORMANCE RATINGS
U-F�r�®p) Sol r Heat Gain Coefficient
• Om29
ADDITIONAL PERFORMANCE RATINGS
- -- - — - -- ------____--
Visible Transmittance Co densation Resistance
4
LM a.u:•r-r..:y-rinl•^rtxtl tluw.r.dlmr nrJ•v:n nr.q,I'c:L4+tf-V:[••�•-ars 1:+
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• Next Steq Living, Inca �t CrHIC.0629266•MA OCABB 9162111•Rl can her ties.#37185
IMPROVEMENTHOME AGREEMENT
Date ofCon.aet: Saturday,March 34,2015 �= next step livingna
home energys0lutions
21 Drydock Avenue.2nd Floor, Boston. Massachusetts 02210
Cusmmer(s)Name(s): Chris Field Telephone: s66-867-8729 s www.neststepliving.com
Customer(-)&reef Adress: 6 West Cir city: Salem State: MA 2Jp: 01970-5429
Custolur(s)Rome,Phone a: Hitme:(716)913-8383 Comt r(s)hfobDc Phone M
PermN(s)Required: , Q�3 Permit Nunber(s)c
City/County Issuing Permu(s): Scheduled Inspection Date:
Custonter(s)jobrdynnd severally agrees to purchase he Products and/or services Of Next Step Living,Inc.("Connector")in ac=%%ith
his Home Improvement Agreement(Step Limem')and the attached speci
Customers)hereby agrees ro sign a completion certificate after Contractor has completed all work under this Agreement
ESTI.WATED STARTING DATE: Saturday,Mardi 28,2015 E61'1)11ATED COMPLETION DATE: Saturday,April 11,MIS
PAYAiENThW1711I (wiectonecptioni PURCHASE PRICE: 5 4,187
oCash HCreditCard DOVW PAYMENT: $ 300
CheerFinancing BALANCE DUE ON SUBSTANTIALCOKLETION: S 3,887
Customers)acknowledges receipt 0f"Reuovale Right:Important Lead Heard Information for Families,Child Care provide Schools".
Customer(s)received this pamphlet on the date of this Agreement,before commencement of work (Customer's Initials
(Rhode Island Cievomm Only)Customer(s)acknowledges receipt of required Contractors'Registration and Licensing Board oonmme�education materials. (Customer's Initials_)
(Rhode Island Cus[omers Only)Notice to buyer:(1)On not sign this Agreement if any of the spaces intended for the agreed terms to the extent
of than available information are left bi ant:-(2)You are entitled to a copy of this Agreement at the time you sign it(3)You may at any time paw
off the full unpaid balance due under this Agreement,and in an doing you may be entitled to receive a partial rebate of the,intone,and
insurance charges.(4)The seller has no right to unlawfully enter your promises or commit any breach of the peace to repossess goads purchased
under this Agreement.(5)You may cancel this Agreement if ithas not been signed at the main office or a branch office of the seller,provided
You motifp the seller at his or her main Office or branch office shown in the Agreement by registered or certified mail,which shall be posted not
later than midnight of the third calendar day after the day on which the buyer signs the Agreement,excluding Sunday and any holiday on
which regular mail deliveries are not made.See the accompanying notice of cancellation form for an explanation of buyer's right"
Customer(s)agrees and understands that this Agreement constitutes the entire un standing between the parties,and that there are no verbal
understandings changing any of the terms of this Agreemenc Customers acluto K)( ) _
understands the terms of this Agreement,and has received a completed(signed, datedhmpy oftthis Agree he eluding the two k
accompanying Notices of Cancellation,on the date first written above and(2)w rally informed of Cus s right to cancel this Agreement.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
NEXT STEP LIVING, INC.
By: Sean Pike 311 412 01 5
Print Name Uc.A Signature Date
CUSTOMERS) 9
Chris Field n 3J14/2015
Print Name Signature
Date
rust Name Signature Date
YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANYTIME PRIOR TO MIDNIGHT OF THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEETHE ACCOMPANYING NOTICE OF CANCELLATION
FORM FOR AN EXPLANATION OF THIS RIGHT. CBLLP2013.NSL.CTMARI
,'d 86£:9091 £l)dV
CITY OF SALEM, MASSACHUSEM
a
Buij DING DEPARTMENT
120 WASHMTONSTREET,3"D RLOOR
L(978)745-9595
FAX(978)740-9846
KINIBERLEYDRISQOLL
MAYOR THomm ST.PMRRE
DIRECTOR OFPUBLICPROPERTy/BUIIAING ODmussIONER
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
WkNt '- `t�,ng9p
(name of hauler)
The debris will be disposed of in: o a- 4 Ue� P�'it�
(name of facility)
(address of facility)
Signat re of a plicant
Q 3- 155
Date