16 WHALERS LN - BUILDING INSPECTION GGI The Commonwealth of Massachusetts
I Board of Building Regulations and Standards CITY
I Massachusetts State Building Code, 780 CMR, 7"'edition ReOvF SALEM
dJanuary
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwe ling
This Section For QfAcial kse Only
Building Permit Number: ate App ed:
c
Signature: J
Building Commissioner/Inspector of Buildings a
SECTION 1:SAJTF#KtOPIWATION
1.1 Property Add ess:l r �n� Assessors Map&Parcel Numbers
I �Ilsn
Lla Is this an accepted street?yes no ap Number Parcel Number
1.3 Zoning Information:.. 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
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?Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne 1 of ecord: c
tie' -ZJe 6 W ke I�" LanY
Name(Prmt) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) a
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units I ther ❑ Specify:
Brief Description of Proposed Work': a tdR Rru !
D �
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1. Building $ 1,50 l 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ / N
❑Total Project Costa (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: '
5. Mechanical (Fire $ i
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount: "
6. Total Project Cost: $ 4 1 ��D 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construcctiony�SuperJisor(CSL) g Z i fl 3 a 3 t I
ml`lut I If W Ill(� License Number Expira[i n ate
Name of CSL-Vol er
Ista 1. s�,i9m #np al17o List CSL Type� (see below)
Addr Type I Description
U Unrestricted yp to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Si na re M Masomy Only
RC Residential Roofing Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 e HoNimmernent Contractor(HIC)
J 6 2-7 2 Z
HIC Com an a IC Re istrant Name Reg
e istration Number
rrS g S 0em 71) g I
Ad � 7'3 dr
q�p_7��-Y3LY ExpiratiSnD.ate
Si 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: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, # 7kk) , as Owner of the subject property hereby
authorize /`�1 C ki'd I�,e dt to act on my behalf,in all matters
relative to work authorized by this building permit application.
( l
4
Signature of Owner Date
SECTION 7b:�OWNEW OR AUTHORIZED AGE T DECLARATION
h �I6 440 f�t!/ llto ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of er 6rAutgonizcd Agent Date '
(Signed under the pains and penalties of a 'u
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(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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
4� The Commonwealth ofMassachuseds
Department oflndustrial Accidents
Office oflnvestigations
I Congress,Street,Suite 100
Boston, MA 02114 2017
www.mass.govldfa
Workers' Compensa on Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information pip Please Print Legibly
Name (Business/Organization/Individual): M j�,Q I �M,4e
Address: v 1?>fts$o1 1-.
City/State/Zip: co D Phone#: 1?7S --7`f5— S 3L,/
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a 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-contractors have g, ❑ Demolition
working for me in any capacity, employees and have workers'
[No workers' comp,insurance comp. insurance.t 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp,insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing thew workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ��tl fvt i/14�f/¢Yl( Q ( emu/
Policy#or Self-ins.Lic. Expiration Date: it d zj N
Job Site Address: t L W J-.4IurS. L kn L City/State/Zip: S-t(yril,/Vt,i M X
Attach a copy of the 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 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 of the DIA for insurance coverage verification.
f do hereby Gerd under he a' and enaftks o er'u that the information provided above is true and correct
Si afore: Date
Phone M
OTwlal use only. Do not write in this area,to be completed by city or town offrciaL
City or Town: Permit/License#
Issuing Anthority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Board of 84uildillt!
'S:rt .. -0
Jcanse: CS 82193
'Restricted to: 00
MICHAELT DEMILLE
5 BRISTOL ST
SALEM, MA 01970
10/30011
8801
Board or Building ReguiAtion;and Sti,achirds
i*.. .......
HOME IMPROVEMENT CONTRACTOR
162722
ExPita.110n: 416,2011 Tr*. 282686-
Type: IndfAclual
MICHAEL THOMAS DEMILLE.
MICHAEL DEMILLE
5 BRISTOL ST
SALEM,MA 01970
Office
of Uonsumner auooLicense or registration valid for individull we only
�:i7, HOME IMPROVEMENT CONTRACTOR
before the expiration date. Iffoand return to:
s 'tip fir, 16272 Type- Office of Consumer Affairs and Business p
"istration:
-2
Mutation
Expiration: 41612013 Individual 10 Park Plaza-Suite 5170
MICHAEL THOMAS DEMILLE
MICHAEL DEMILLE
5 BRISTOL ST Undersecretary
SALEM.MA 0197c
Not valid without signature
d
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STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK-INT/EXT/PATIO DOOR
LOWE'S OF DANVERS, MA., STORE# 1094 STORE PHONE: (978)646-9099
1 1153 ANDOVER STREET SALESPERSON: DENNIS GLENNON
DANVERS, MA 01923 SALESPERSON ID: 1227928
Document Print Date : 07/09/2011
This is only a Quote for the merchandise and services printed below.This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree-
ment, including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, and any
other addenda or attachments hereto, shall be referred to herein as this"Contract."
PLEASE READ THIS ENTIRE DOCUMENT, INCLUDING THE "TERMS AND CONDITIONS." BEFORE SIGNING
Lowe's Registration or Contractor license Number/Lowe's Contractor Name
Lowe's Home Centers, Inc.'s MA HIC NO.: 148688 Lowe's Home Centers, Inc.'s FEIN: 56-0748358
Customer Name Home Phone
S NATAN FINKELSHTEYN 978-741-4370
O Customer Address Other Phone
16 WHALERS LN
L City State/Province Zip/ Postal Code
D SALEM MA 01970
Installation Address
T 116 WHALERS LN
O Installation City Installation State/Province Installation Zip/Postal Code
SALEM MA 01970
MERCHANDISE AND INSTALLATION SUMMARY
MERCHANDISE SUMMARY
62151 : 748171590516 : STK : 6'THERMASTAR SLIDING DR SCREEN : 6 THERMASTAR SLIDING DR SCREEN : PELLA CORPORATION - QTY 4
98458 : 07526: STK : PVC BRK MLD WHITE 8FT : PVC BRK MLD WHITE 8FT: EAST COAST MILLWORK DISTRIBUTI -QTY 12
332329 : 748171615776 : STK : 6' TSTAR BVL DR ADV LOWE NO SCR : 6' TSTAR BVL DR ADV LOWE NO SCR : PELLA VINYL PATIO DOORS EAST-
QTY 4
Materials Price $ 1574,00
INSTALLATION DESCRIPTION
.Stdre 1094 Project No. 330682537 for NATAN FINKELSHTEYN Page 1 of 7
STORE COPY
Stock or SOS : Stock Door Type : Patio
Select Location : Back Door Select New Door: Sliding
Number of"Doors to Install : 4 Side Lights or Transoms : No
Hidden Damage Description`. None Number of additional holes bored for accessories : None
Install Specialized Mortise Hardware : No Lead Safe Practices : No
Total Linear Feet of Custom Trim to be Installed :0 Deliver Door: Yes
Customer Understands Scope of the Project : Yes Permit Required : No
Additional Miles Traveled over 20 : 0 Bring Up To Code Description : None
Local Disposal Fee : None Describe Other Work Needed : patio access[2/3]flrs.
Other Work Charge : Yes Comments : No Comment
Labor Charges $ 2676.0
Detail Deduction -$ 0.00
Additional Specifications:
Notation: Lowe's will not make structural modifications, paint or stain or remove/reinstall security system equipment. Customer is responsible to advise if prop-
erty is governed by Historic District Regulations.
Additional Specifications:Federal law requires Lowe's to provide you with the pamphlet Renovate Right: Important Lead Hazard Information for Families,
Child Care Providers and Schools. 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.
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES where applicable
SUB-TOTAL $4250.0
*TAX $ 0.0
DELIVERY $ 0.0
ORDER TOTAL $4250.0
BALANCE DUE
Work is to commence upon reasonable availablity of Contractor which is anticipated to be ' CJ date].
,Store 1094 Project No. 330682537 for NATAN FINKELSHTEYN Page 2 of 7
/
STORE COPY
Estimated completion;date is ]fill in date].
NOTICE TO CUSTOMER
All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing
on this contract form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation
necessitated by defective substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to custom-
er.
IF THE CONTRACT TOTAL IS$1 000 00 OR LESS Customer must pay in full
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS 1 000 00•
[_] Customer to Pay in Full; OR
[_] Customer to use the following payment schedule:
(1) Deposit$ to be paid upon signing contract. Deposit should be 1/3 the total contract price; and
(2) Payment of $ to be paid anytime after this Contract is signed and before commencement of installation, I/We authorize Lowe's to do
one of the following (check appropriate box below):
(_] Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or
L] Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed; and
(3) Final payment of$100.00 to be paid upon completion of the installation and both parties' satisfaction.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON-
TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU
HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPY
OF THIS CONTRACT AT THE TIME OF SIGNATURE.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c 142A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON-
TRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET-
ARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB-
MIT T SUCH ARBITRATION AS PROVIDED IN M.G.L. . h
By: OUC// I Date:` 7 l9/f
Lows Home Centers, Inc.
By: Date:
Store 1094 Project No. 330682537 for NATAN FINKELSHTEYN Page 3 of 7
STORE COPY
o
By: - % Date:
Spouse
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION
INITIATED BY LOWE'S PURSUANT TO M.G.L. c.142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION
EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY6SIGNED BY THE PARTIE .
WITNESS OUR HAND(S)AND SEAL(S) BELOW THIS DAY OF <7
Lowe's Home Centers, Inc.
By: 4a"13e L29 (Seal)
Print Name: 1
/ / `l�Pk %(�G Gic _ (Seal)
Address
per
CTl yy State/Province Zip/Postaarreode Print Name
(Seal)
Co-Owner or Witness
Print Name
CustomR acknowledges receipt of a true copy which was completely filled in prior to Customer's execution hereof. You the customer may cancel this transaction
at any time prior to midnight on the third business day after the date of this transaction. See the attached Notice of Right to Cancel for an explanation of
this right.
Store 1094 Project No. 330682537 for NATAN FINKELSHTEYN Page 4 of 7