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12 WILLIAMS ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY OF Ir Board of Building Regulations and Standards SALEM �A Massachusetts State Building Code,780 CMR vised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Dem sh a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Date z 1�'UGiN.LtC.L. L�^ Building Official(Print Name) - Si mre Date a SECTION.1:SITE INFORMATION 1.1 Prope Address: 1.2 Assessors Map& el Numbers J Z l Vl/�AuS 5S Ma Number - Parcel Number Y l.la Is this an ccepted street?yes ., no P 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(it) 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? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owne f R r . 71 Name i Citty,,State,ZIP r� zS'�/ �,Y � No.and Street f Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) El Alteration(s) ❑ Addition ❑ f Demolition ❑ Accessory Acce Bldg. ❑ Number of Units_ Other ❑ Specify: _ GJI. Brief Description of Proposed World: � C. SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials 1.Building $ Q, 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees:"$ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ Su ression r -Check No. -Check Amount' Cash Amount: 6,Total Project Cost: $ 2/2 0.,5 7 13 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street 1J - Type Description U Unrestricted(Buildings up to 35,000 cu.ft. NN A/N 1 R Restricted 1&2 Family Dwelling City/Town, fate ZIP M Masonry RC Roofing Covering WS Window and Siding Q � �_�� SF Solid Fuel Burning Appliances 7 I Insulation Telephone Email address D Demolition 5�.2..�RRegistered Home Improvement Contractor(HIC) /61-54- IVO //.a `6 �D�l�/..I HIC Registration Number Expiration Date HI Co - y N e or HIC Registrant Name /o 0/1 2 N dStreet / / -/ ` ��y�� Email address City/Town,S ZIP Telephonel4e�� 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 APPL FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on y behat i all matters relative to work authorized by this building permit application. Print Owner' ame(Electronic—Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information contained i ication is true and accurate to the best of my knowledge and understanding. P t 2yers or Authorized Agent's Name(Electronic 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(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.cov/oca Information on the Construction Supervisor License can be found at Amy.mass.aov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.f.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.f.) 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 Cast" 9� Office of Consumer Affairs and usiness Regulation 10 Park Plaza.- Suite 5170 Boston,Massachusetts 02116 Home Improvement'Goni actor Registration - Registration: 165640 - --. Type: LLC I _ Expiration: 3/15/2012 Tr9 2MS87 AIR—TIGHT LLC_ WEATHERAZATIOi — JAMES FORTIN - 10 PINE KNOLL DR. _ 1 BEVERLY, MA 01915 ' - -- - Update Address and return card-Mark reason for change - [j- Address C) Renewal r,:l Employment V Lost Card I ✓�1 aammuud-ea�i c�� 1 � License or registration valid for iuditfdul use only 1 :Of icc of Consumer Affa'us&Business Reanladou before the expiration date. If found return to: m HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation �` - Registration 165640 10 Park Plaza-suite 5170 Expirabon 9f"tWl2 Tr 294587 Boston,MA 02116„ Type.:::: AIR-TIGHT LLCitJ€,4THER>i!ATION JAMES FORTIN - �— v 10 PINE KNOLL Olt \�-'_ BEVERLY,MA 07915 Uodersecrenuv e� \Noy valid without signature Massachusetts- Department of Puhlic Sal'etc i Board of Buildin_ Re ulatinns and Standards Construction Supervisor License License: CS 52576 JAMES E FORTIN 10 PINEKNOLL DR t BEVERLY,MA 01915 Expiration: 101312M3 Coanuissiwrer - Tr': 6700 . A-he.Commonwealeh ofMarsackuuwo td ,p¢pmttnantofTndustriaiAccidenLs offiae oflnvestigadons 600-Washington Street kv. Boston,MA 02111 www.m agovldia ers Workers' Compensation Insurance Affidavit:BuilderslCantxactors/P'I Pletlse Print L b Avpftcant Infolm 'o - aonRadividuaQ' `� G � -i3alne(Butinesslthgatd�a• - - Addfess: Citylsttlte &P.— erg e-� \ Phone#: F2-O u an employer?Cheekthe ap riata box: Type of project(txquired): general contractor and I New construction tma employer with _a4' have lured the sub-contractors 6mployeas(full sndlor part time) �md on the attached sheet.= 7. ltemodeliogam a sole proprietor orpareaer- .lh�sob- orshave 8. Demolitionhip and have no employees workers'comp.insuwnae. 9. E]Building additionorking for in any capacity`• [No workers'comp.insurance 5. We are a havecorporationcis and its 10.©Electrical repairs or additions required.] officers have exemption. ped their airs or additions 3.❑ I am a homeowner doing all work right of exempttan per MGL 31.[]Phtmbing�P myself[Noworkeas'txunp. c. 152,§I(4),and wehavemo 12.(]Roofrepairs # employees.[NoWorkers! 13.E Other IVIS% 4 insurance rt quitad.] comp.insurance required.]- •Any appoc"orughtdM boxil roe do ffitoat the section bdawahowias thdr workara'eompetuatioa policYiat'armation. trtmoeowncawhoaivgoathieatadavaindk,*sfhoyamdoingallwadundthaahkeontsideconnardmsmeshaaewn6rdarh;°dim mimioch. tCoxaeetatadmtdrek do box mmtariaehad as tatdittonai eta etahowmgibe nettm�theaab•eanitaetots and thew vtodma'comF Pd'cy6 i'aarairemyrloyer that is prow'dhg wor*e+s'eoapellAadon hastaance far my etaphryem Below is tht policy m+d fa6 site injvrmatlon �- Insrrornee Company Name Policy#or Self-ins.Lie.# 1l wlG 1 to ti Expiration i m• !i,{�{ OJT Job site Address: lt7il1%� �� cilyfsffiterLip: ���'^ Attach a copy of the workers'mrnpensstton policy declaration page(showing the policy number and ind ppiraiion date Ftrilme to mom coverage as required under Section 25A of MGL c.152 can lead to the imposition ofcriminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civilpermities in the form of a STOP WORK ORDER and a fine ofup to$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to dw Office of Investigations ofthe DIA for insurance coverage verification. !do hereby cer*anderthepains andpenaftin ojpedwY d at the WOrm Lion pravlded a is artdcvrred e#: offrdal use only. Do nat write l9 thts area{to he coiMIded by city or town offidat City or Town: Permltt iceuse# Issaing puthorlty(circle one): 1.Board of HeaNh 2 Smiling Department 3.CkyPfown Clark 4.Blectrical inspector S Pltrtnbing Ins. 6.Other Contact Persorc Phone# MOYNIHAN LUMBER OF BEVERLY, INC. "QUALITY BACKED BYA DESIRE TO PLEASE" 82 River Street P.O.Box 509 FEIN:04-2261995 Beverly,MA 01915-0509 "AA Contractor Reg No.: 978-927-0032 HH Exp.Date: /— Salesperson(s): HOMEOWNER INFORMATION gA/tt3aA / QA) `l78 Name Daytime Phone l z aOiI�iIOA" -S9 Street Address(Not P.O.aox) - Evening Phone 6944 Ill C�)? n Cfty/Town State Trp Code Mailing Address(d different from Street Address) WORK TO BE PERFORMED AND MATERIALS TO BE USED Moynihan Lumber of Beverly, Inc.agrees to perform the work set forth in Exhibit A for Homeowner and to use such materials in connection therewith as set forth also in Exhibit A,attached hereto and made a part hereof. The following schedule shall be adhered to unless ci.rcumstaDpes arise beyond Moynihan Lumber of Beverly, Inc.'s control:Work scheduled to begin: _/ _ Expected date of completion: May be based Eogyffval ofspecial order material TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Moynihan Lumber of Beverly, Inc. agrees to a oat work,and furnish the material and labor set forth in Exhibit A for the Total Contract Price of:$ 2 .6 (which amount includes all finance charges). PaymentsjShall oe made by Homeowner according to the following payment schedule: $ J 0' Initial deposit upon signing this Contract(the initial deposit shall not exceed the greater of one-third(1/3)of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom Orders as se forth below). $ by_LLL—or upon completion of delivery of materials $ by_/_/ or upon completion o install l $� upon completion of the Contract�/jU i/�2fwol� In order to meet the completion Schad set forth above,the following materials/equipment ust be special ordered before the Contract work ins,fora Total Cost of Special/Custom Orders of$ B to be paid for uilding permit to be paid r $ to be p ' for O OT SIGN THIS CON RACT IF THERE ARE ANY BLANK SPACES -Moynihan Lumber of Bevedv.Inc. ',171/Z Homeowngfs Signs re 6ate Contractor Dat'76 Homeowner's Name(Printed) - Nam (Printed)and Title c1 Signatory You'may cancel this Contract if it has been signed by a party thereto at a place other than an address of Contractor,which may be its main office or branch thereof, provided you notify Contractor in writing at its main office or branch by ordinary mail posted, by telegram sent or by delivery, no Teter than midnight of the third business day following the signing of this Contract. See attached notice of cancellation for an explanation of this right. 1057-.BEV 4/09 White-Office. Yellow-Sales/Service Pink-Customer Pagel of I